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♦ • 






United States 
Environmental Protection 
Agency 


C 


Environmerttal Research EPA-600/1-78-070 

Laboratory December 1978 

Athens GA 30605 

Research and Development 

Schistosomiasis in 
Rural Egypt 

A Report of U.S.- 
Egyptian River 
Nile and Lake Nasser 
Research Project 



T 










RESEARCH REPORTING SERIES 


Research reports of the Office of Research and Development, U.S. Environmental 
Protection Agency, have been grouped into nine series. These nine broad cate¬ 
gories were established to facilitate further development and application of en¬ 
vironmental technology. Elimination of traditional grouping was consciously 
planned to foster technology transfer and a maximum interface in related fields. 
The nine series are: 

1. Environmental Health Effects Research 

2. Environmental Protection Technology 

3. Ecological Research 

4. Environmental Monitoring 

5. Socioeconomic Environmental Studies 

6. Scientific and Technical Assessment Reports (STAR) 

7. Interagency Energy-Environment Research and Development 

8. "Special” Reports 

9. Miscellaneous Reports 

This report has been assigned to the ENVIRONMENTAL HEALTH EFFECTS RE¬ 
SEARCH series. This series describes projects and studies relating to the toler¬ 
ances of man for unhealthful substances or conditions. This work is generally 
assessed from a medical viewpoint, including physiological or psychological 
studies. In addition to toxicology and other medical specialities, study areas in¬ 
clude biomedical instrumentation and health research techniques utilizing ani¬ 
mals — but always with intended application to human health measures. 


This document is available to the public through the National Technical Informa¬ 
tion Service, Springfield, Virginia 22161. 







EPA-600/1-78-070 
December 1978 


SCHISTOSOMIASIS IN RURAL EGYPT 
A Report of U. S.-Egyptian River Nile 
and Lake Nasser Research Project. 


by 

F. DeWolfe Miller 
Mohamad Hussein 
Khalil H. Mancy 
Morton S* Hilbert 
The University of Michigan 
School of Public Health 
Anil Arbor, Michigan, U.S.A, 48109 

and 

The University of Alexandria 
High Institute of Public Health 
• Alexandria, A.R, Egypt 


Special Foreign Currency Project No. 03-542-1 


Project Officer 

Walter M. Sanders, III 
Environmental Research Laboratory 
Athens, Georgia, U.S.A. 30605 


ENVIRONMENTAL RESEARCH LABORATORY 
OFFICE OF RESEARCH AND DEVELOPMENT 
U.S. ENVIRONMENTAL PROTECTION AGENCY 
Athens, Georgia 30605 


DISCLAIMER 


This report has been reviewed by the Environmental Research Laboratory, 
U.S. Environmental Protection Agency, Athens, Georgia, and approved for 
publication. Approval does not signify that the contents necessarily reflect 
the views and policies of the U.S. Environmental Protection Agency, nor does 
mention of trade names or commercial products constitute endorsement or 
recommendation for use. 


*S3S3le> 


\ \ 



\ 


\ 


\ 


\ 


\ 


\ 


\ 


• • 

11 



/ 



FOREWORD 


After centuries of annual flooding and droughty the 
constuction of the Aswan High Dam has povided effective flow 
control to the River Nile as it enters the fertile Egyptian 
Nile Valley. The dam has resulted in the production of 
hydroelectric power for municipal, agricultural, and 
industrial use, and the continuous availability of water has 
increased agricultural productivity. Optimum benefits from 
a project of this magnitude cannot be fully realized, 
however, until the major environmental, agricultural, 
social, economic, and public health impacts have been 
incorporated into strategies for managing the water 
resources within the basin. In 1975, the U.S. Environmental 
Protection Agency and the Ford Foundation began support of 
a 5-year, multifaceted research program conducted by the 

Academy of Scientific Research and Technology and 
related institutions and the University of Michigan to 
provide the information needed for comprehensive water 
quality management in the Nile Valley. 

Although the project addresses issues of vital 
importance to Egypt, the knowledge gained also will be of 
significant benefit to the general scientific community. 
For example, water resources management models developed for 
the Nile Basin can be applied to some river basins in the 
United States. 

This report, the first of a series growing out of the 
public health portion of the U.S.-Egyptian project, 
describes a research study of the prevalence of 
schistosomisasis--a chronic disease of the liver, bladder, 
and lungs--following the regulation of water flow in the 
river, canals, and drainage ditches brought about by the 
dam. 

David W. Duttweiler 
Director 

Environmental Research 
Laborator y 
Athens, Georgia 


PREFACE 


The Aswan High Dam was built for the purpose of water 
storage, river flow control and hydroelectric power 
production. The fulflllraent of these goals is of vital 
importance for Egypt's agricultural and industrial 
development programs. This can be easily realized since the 
River Nile constitutes 90% of Egypt's fresh water resources 
and the present population of 38 million people inhabit 
approximately four percent of the land and the rest is 
barren desert. Nevertheless, since its inception, the Aswan 
High Dam has been under unprecedent attacks in the news 
media and the scientific literature. It has been blamed for 
causing serious ecological perturbation which resulted in 
reducing the fish population in the Mediterranean, lowering 
the fertility of the Nile Valley, and markedly increasing 
schistosomiasis in Egypt. In contrast to the above claims, 
our study indicated a marked decline in schistosomiasis 
prevalence in rural Egypt over the past forty years. 


These research findings are the outcome of a 
comprehensive ongoing project dedicated to the study of the 
River Nile and the impacts of the Aswan High Dam on 
multipurpose river uses. This includes irrigation, 

community water supply, fishery, recreation, transportation, 
etc. The aim of this project is to provide the decision 
makers in Egypt with river management alternatives 
compatible with government goals for economic development. 
This includes the assessment of trade-offs and predictions 
of the outcome of each river resources management 
alternative. This is a joint project between the Egyptian 
Academy of Scientific Research and Technology and the 
University of Michigan. The technical and financial support 
of the U.S. Environmental Protection Agency, the Ford 
Foundation, and the ^^orld Bank is highly appreciated. 


Khalil H. 
Principal 
July 17, 1 


Mancy 
In ves 
978 


tigator 


IV 






ABSTRACT 


The prevalence of schistosomiasis in Egypt has been 
high for a long time as a result of widespread irrigation 
schemes. The possible effect of the proposed Aswan High Dam 
and the resulting formation of Lake Nasser on the prevalence 
of schistosomiasis created a controversy in both the public 
and scientific press. It was speculated that the Aswan High 
Dam and related irrigation development would contribute to 
an increase in schistosomiasis. 


The objectives of this s^udy were to provide current 
information on the prevalence of schistosomiasis throughout 
Egypt^ to establish trends in the prevalence of 
schistosomiasis in order to shed light on the potential 
changes caused by the Aswan High Dam, and to determine 
correlations between certain environmental variables and 
schistosomiasis prevalence. 

\ 

. This research was divided into two studies. The first 

\ ^ was a field study in thirty-three villages located in Upper 
Egypt, Upper-Middle Egypt, and the Nile Delta. In the 
second investigation, eight villages were selected in the 
resettled Nubian population in Kom Ombo. The sampling 
methodology used insured that the probability of selection 
could be calculated for any given person sampled. To 
evaluate these findings, extensive historical data on 
schistosomiasis prevalence in Egypt were compiled and 
assessed for factors of comparability. 


The overall prevalence of schistosomiasis, corrected 
for differences in sampling fraction and age, in seven 
villages in the north central Nile Delta was 42.1%, in six 
villages in Upper-Middle Egypt (in the governorate of Beni 
Suef) the overall prevalence was 26.7%, and in the sixteen 
villages in the governorate of Aswan, the prevalence was 
4.1%. Prevalence was invariably higher in the male 
adolescents with the differential between sexes increasing 
from north to south. The prevalence was significantly lower 
in those villagers who obtained water for domestic use from 
protected supplies. Villages in Upper Egypt located on dry 
barren ground had a much lower prevalence, by five times, 
than the villages surrounded by cultivated lands. The 
effect of population growth and migration from rural to 
urban areas on schistosomiasis prevalence and distribution 
was discussed. 


Results based on trend analysis of current and past 
data indicated a strong decline in overall prevalence of 
schistosomaisis in the rural population over the past forty 


V 


years. The data did not show an increase in the overall 
prevalence of schistosomiasis following the construction of 
the Aswan High Dam. The Nubian population also experienced 


schistosomiasis prevalence 
transmission were discussed, 
information presented here 
schistosomiasis transmission 


it ing 

more 

than others. 


were 

also 

correlated aga 

inst 

and 

addi t 

ional aspects 

of 

I 

t is 

hoped that 

the 

on 

the natural history 

of 

i n 


will aid in 

t he 


This research was implemented through the River Nile- 
Lake Nasser project, a joint University of Michigan-Eqyptian 
Academy of Scientific Research and Technology project, and 
funded by the (J. S. Environmental Protection Agency and the 
Horld Bank. 


VI 




TABLE OF CONTENTS 


FOPEPORD. iii 

rPEFACE. iv 

ABSTRACT ........... ▼ 

LIST OF TABLES • . . . ix 

LIST OF FIGORES. . xiii 

ACKNOWLEDGEMENTS . xvi 

CHAPTER 

I. INTRODUCTION. 1 

The Disease: Schistosomiasis 1 

Life Cycle of Schistosomiasis. ...... 2 

The Setting: Egypt . ....... 3 

Dams^ Irrigation^ and Schistosomiasis. . • 4 

The Controversy. 10 

Research Objectives. ..... . 11 

IT. REVIEW OF LITERATURE. 13 

Introduction ............... 13 

Background Work on the Prevalence of 

Schistosomiasis. ..... . .. 14 

Schistosomiasis in Egypt ......... 15 

Country Wide Prevalence Surveys ... 16 

Schistosomiasis in the Nile Delta . . 24 

Schistosomiasis in Upper-Middle Egypt 38 

Schistosomiasis in Uppe'r Egypt. ... 46 

Schistosomiasis in Nubia. .. 50 

Schistosomiasis in Lake Nasser. ... 56 

Schistosomiasis in the Desert and 

Reclamation Sectors . .... 59 

Schistosomiasis in Egypt; A Summary. 60 

Irrigation Expansion and the Aswan High 

Dam. .. 61 

Environmental Health Conditions in Egypt . 66 

III. MATERIALS AND METHODS. 77 

Description of the ’’Downstream Study”. . • 77 

Description of the ’’Nubian Study”. .... 78 

Hypotheses. 79 

Data Acquisition.. 80 

Specific Data Collected. 81 

Selection of Field Survey Sites. 82 

Data Collection Teams. .......... 86 

Review of Facilities and Preparation of 

Materials. .. 86 

Preservation of Stool and Urine Specimens. 89 

. . 

vn 





























Examination of Stool and Orine Specimens • 90 

Selection of the Sample Population • • • • 92 

Examination of the Environment and the 

Population ••• . ••...• 94 

Data Management and Analysis «••••«• 97 

Adjustment Scheme.. • • • • 99 

IV. RESULTS .. 100 

Results of the Downstream Study. • • . • • 100 

Selection of the Sample and Response. 100 

Age-Sex Distribution of the Sample. . 101 

Overall Prevalence of Schistosomiasis 
in the Study Areas. •«••.•••. 101 

Age Sex Distribution of 

Schistosomiasis in the Study Areas. . 114 

Environmental Aspects of the 

Downstream Study Sites. •««..•• 120 

Results of the Resettled Nubian Study. • • 130 

Selection of the Sample and Response. 130 

Age-Sex Distribution of the Nubian 
Sample. 130 

Overall Prevalence of S.haemato bium 

in the Nubian Sample. .. 130 

Environmental Aspects of New Nubia. • 132 

V. DISCUSSION AND CONCLUSIONS. .. 142 

The Downstream Study: General Aspects. . . 142 

Water Supply and Schistosomiasis ..... 146 

Distribution of ma n soni and the AHD . . 147 

General Estimates of Schistosomiasis ... 148 

Secular Trends in Schistosomiasis. .... 151 

Population Changes and Schistosomiasis . . 156 

The Nubian Study ............. 159 

REFERENCES .. 163 

Appendix I..................... 174 

Appendix II. .................... 175 

Appendix III .................... 190 

AppendixIV.. . . . . . • .. . ... .. .. .. . 194 


vn 1 






















LIST OF T.^BLES 


Page 

1. Effects of conversion from basin irrigation 
to perennial irrigation in Kom Ombo, Upper 

-UYPt .. 7 

2. Suminary of prevalence surveys for 

bilharziasis in Egypt, by area, year, and 
author..., . , 15 

3. Surveys of bilharziasis completed between 

18 66 and 1 92 4. 17 

4. Prevalence of bilarziasis in the Nile Delta 

in 1935 . 18 

5. Prevalence of bilharziasis in areas south 

of Cairo in 1935. After M. A. Azin (1935) ... 19 

6 . Comparison of results of two surveys, Scott 

(1935) and EMPH (1955) for schistosomiasis in 
different regions of Egypt. •••••«••.. 25 

7. Prevalence of urinary schistosomiasis by 
age and sex among 60,197 persons surveyed in 23 
villages in different locations in Egypt in 

1955 by the EMPH. ............... 32 

8 . Corrected estimated prevalence of 
bilharziasis in the Egypt-49 project area by 

division. ......... . ..«*• 35 

9. Prevalence of schistosomiasis in Kafr El 

Sheikh, Nile Delta. 37 

10. Percent prevalence of schistosomiasis in 

the northwestern Nile Delta by selected years.. 39 

11 . Age-specific prevalence of ^ haematobiu ii 

intheFayoum, 1949. . . . . • .. . . « • • . 41 

12. A summary of results taken from a survey 
for haem ato bium in the area between Assyut 

and Aswan in 1972 by Dazo Biles (1972). .... 49 

13. The percent prevalence of h aem at obium 

in Nubia, 1958. .. 53 

14. Age-specific prevalence of haemato bium, 

Nubia, 1958.. 54 


IX 

















15. Distribution of individuals who submitted 
urine and/or stool specimens by age, sex, and 
locality (Tribe), Nubia, Egypt, U.A.R., 1963. 

After Zawahry (1964), ..... . ... 55 

16. Percent prevalence of bilharziasis by age 

and sex; Mubia, Egypt, fl.A.P., 1963. 57 

17. Percent prevalence of bilharziasis by 

locality (tribe) and sex; Nubia, Egypt. .... 58 

1B. The status of irrigation schemes in 

Dpper-Middle Egypt and Upper Egypt by year. . . 63 

19. Conversion to ’’permanent” irrigation by 

year in selected governorates 65 

23. Aggregate cropped surface (’000 feddans) . 67 

21. Distribution of examined population by 

source of water supply.. 71 

22. Distribution of examined population by 

type of housing.. 71 

23. Water and waste-water facilities in Upper- 

Niddle Egypt in 1975. ••...•••••.•• 72 

24. Tribe, location, village, and number 

of families selected in Nubia, 1960 •....« 73 

25. Housing characteristics. Old Nubia, 1960 . 74 

26. Water supply and lighting in Old Nubia, 

1960. .. 75 

27. The pattern of selection and response 

in the Downstream study sites.. .. 102 

23. The number of persons attending the 

Downstream study by age and area. ••••••• 104 

29. The number of persons examined in 

Kafr El Sheikh by age and site. ••••««.. 105 

30. The number of persons examined in 

the Beni Suef study area by age and by study 

.... 106 

31. The number of persons examined in the 

Aswan area by age and by site ......... 107 

32. The overall prevalence of schistosomiasis 
in the Kafr El Sheikh study area 

X 


109 

















111 


33. The overall prevalence of schistosomiasis 
by study site in the Kafr El Sheikh study area* 

34. Prevalence of h aem a tobiu m in the Beni 

Suef study sites^ Upper-Widdle Egypt. ..... 112 

35. Overall prevalence of haematobiu m in 

the study sites of the Aswan governorate. ... 114 

36. Results of the subsarople in Bimban^ Aswan. 115 

37. The number examined and percent positive 
by age and sex in the Kafr El Sheikh area for 
all those infected with both S^ haemat obium and 
Si niansoni and infected with either or both 

species.. ....... . •**.* 118 

38. Age-sex distribution of haem atobi um 
infection in the sample from the Beni Suef 

area* . .. •.....• . 120 

39. The number examined and the percent 

positive by age and sex for ^ hae matobiu m in 
the Aswan study area excluding the results from 
Bimban (10).. .•••••••*.••.•*•• 121 

40. The number examined and the percent 
positive by age and sex for ^ haematobiu m in 

the Bimban (10) subsample.. ••••«•••«* 123 

41. The prevalence of schistosomiasis and the 
distribution of persons per standpipe in the 

Kafr El Sheikh study area.. *«......•« 124 

42. The number of persons in the sample from 

Kafr El Sheikh by water source and use. .... 124 

43. The percent prevalence of haem atobium 
by source and use of water supply from Kafr El 

Sheikh study area.. «.«•.•••****•• 126 

44. The percent prevalence of manson! by 
source and use of water supply in the sample 

^rom Kafr El Sheikh.. .•.••*.*••«•• 128 

45. The prevalence of schistosomiasis and the 
distribution of persons per standpipe in the 

Beni Suef study area.. 128 

46. The number of persons in the sample from 

Beni Suef by water source and use.. ...... 129 


XI 























47. The percent prevalence of hae iaatobium 
by source and use of water supply in the sample 

from Beni Suef. ... 129 

48. The number of persons per standpipe by 

study site in Aswan.. ... 132 

49. Percentage of homes with latrines and the 
relationship to schistosomiasis prevalence in 

the Aswan study sites.. «•.••..««•«. 133 

50. The pattern of selection and response in 

the Nubian sample .•«*••• . 135 

51. The number examined and the percent 
positive by age and sex for haem atobium in 

the Nubian sample.. 137 

52. The percent prevalence of haem atobiu m 

in the Nubian sample by study site. ...... 140 

53. Estimated prevalences for the different 
Downstream study areas based on special 

assumptions stated in the text. 150 

54. Nile Delta: Percent prevalence of 

schistosomiasis for selected years. ...... 152 

55. Upper-Middle Egypt percent prevalence of 

S,*. haematobium by selected years. ••..••. 154 

56. Table showing the results of certain 
assumptions made on the prevalence of 
schistosomiasis in respect to population 

changes in Egypt. •«......«. . 157 


• » 

xn 

















LIST OF FIGaRES 


Page 

1. A nap of Egypt in the 1930 *s. . 5 

2. A map of Egypt in three parts, divided 
roughly into Lower Egypt (Nile Delta) , Upper- 

niddle Egypt, and Upper Egypt.* • 6 

3. A map of Egypt taken from Scott (1937), 
that shows the prevalence per 100 of 

S* haema tobium among persons examined at EMPH 
traveling hospitals during the 1930*s«« • • • • 21 

4. A map of Egypt showing the prevalence per 
100 of S_^ h aemat ohium among rural persons 

examined at their homes by Scott (1937)•• • • • 22 

5* Two maps of the Nile Delta showing the 

percent prevalence of ma nson i during the 

1930*s, 23 

6 . The prevalence of schistosomiasis in four 

surveys., • . •••««•••• 30 

7. The distribution of schistosomiasis by age 
in the Egypt-49 project area and in its four 

divisions.. ••.•••.••••••••••• 34 

8 . This graph was plotted after data obtained 
from the EMH (1975) for the Fayoum governorate 

schistosomiasis control project. 43 

9. The age-sex specific prevalence of 

5. haematobi um in selected sites of the Beni 

Suef governorate in 1972. •••«..•«••. 45 

10. This is a photographic reproduction made 
by a LANDSAT satellite of Upper-Middle and 

Upper Egypt. 47 

11. This is a map of the Korn Ombo area showing 

the resettlement pattern of the Nubian tribes., 52 

12. A ’’floating pump station” in Qena. .... 64 

13. The relationship between population growth 

and agricultural expansion. . .. 68 

14. This is a sketch map of the Kom Ombo area 

showing the distribution of health units and 
centers.. 85 


XT 1 1 


















15. The age distribution by study site in the 
Kafr El Sheikh study area.. 

16. The age distribution by study site in the 

Beni Suef study area... "^09 

17. The age distribution by study site in the 

Aswan study area.. 110 

18. The adjusted age distribution from the 
Kafr El Sheikh s^udy area compared to the age 
distribution for this same rural area according 

to the 1960 census data (CAPMAS, 1960). .... 113 

19. The adjusted age distribution from the 
Beni Suef study area compared to census data 

for this area (CAPMAS, 1960). 116 

20. The adjusted age distribution from the 
Aswan study area compared to census data for 

this same region (CAPMAS, 1960).««•*«..• 117 

21. The adjusted age-sex prevalence 
distribution for schistosomiasis for all study 
sites combined in the Kafr El Sheikh study 

area. 122 

22. The adjusted age-sex prevalence 
distrioution for S^ haem at obium infections for 
all study sites in the Kafr El Sheikh study 

area. ..... . .•••..««. 125 

23. The adjusted age-sex prevalence 
distribution for raansoni infections for all 

study sites in the Kafr El Sheikh study area. . 127 

24. The adjusted age-sex prevalence 
distribution for infection with both species 
for all study sites in the Kafr El Sheikh study 

area. ..... . ......... 131 

25. The adjusted age prevalence distribution 
for those infected with both species and for 

those infected with either or both species. . . 134 

26. The adjusted aae-sex prevalence 
distributon for Sj. haematobijyn infections in 

the study sites from the Beni Suef study area.. 136 

27. The adjusted age-sex distribution for 
S_. haemat obi um infections in the study sites 

from the Aswan study area.. .......... 138 


XIV 














28. The age distribution by study site in the 

Nubian sarapie*. ...••• . 139 

29, The adjusted age prevalence distributon 
for hae m atobiu m infections in the Nubian 

sample. ..141 


XV 






ACKNOWLEDGEMENTS 


This is a very important section* The size and scope 
of the activity necessary to compile data on over 15,000 
persons living in 41 rural Egyptian villages located at the 
extremes of the Nile Valley in Egypt is understated in the 
main body of this thesis. An undertaking of this magnitude, 
vhich took me to Egyp*- for almost three years, obviously 
required the participation of many others. So many, in 
fact, that as I write this section a stream of faces, 
persons, friends that I met and who helped me in many, many 
ways comes to my mind and shape not just a series of 
repeated encounters, but an incredible story about some very 
reassuring aspects of human relationships. The format of 
this section, however, limits my story to essential aspects. 
This is not to say that the many that are not mentioned here 
because of spatial limitations have been forgotten, but 
rather, to whom I will be forever grateful. 

Foremost in making this study a reality was my 
Egyptian mentor. Dr. Mohamad Hussein, Dean of the High 
Institute of Public Health at the University of Alexandria, 
Alexandria, Egypt. Aside from the many details which I was 
totally unable to acquire and which Dr. Hussein acquired for 
me, such as various governmental approvals. Dr. Hussein was 
unfailing in his support, patience, and kindness. His 
technical steerage was invariably accurate and vital. The 
technical and cultural blunders I would have made without 
his assistance would have circumvented any measure of 
progress or success that I might have made otherwise. I 
consider myself fortunate that I was able to study and learn 
under the direction of Dr. Hussein. 

Inadequate as it is as an expression of gratitude, a 
list has been prepared of special persons in Egypt whose 
help has been invaluable. 

Dr. Baha Hashem, Director-General of Pural Health, the 
Egyptian Ministry of Health (EMH). Assigned to the 
project as representative team leader from the 
Ministry, Dr. Hashem’s help in obtaining the 
cooperation of the rural health staff was invaluable. 

Dr. Ahmad Naqaty, Vice-Director-General of Rural 
Health, EMH. Dr. Nagaty was very helpful with advice 
on methodology and transportation. 

Dr. Lotfi Abdel Khalek, Director-General of Health, 
Beni Suef. Dr. Khalek's enthusiasm for field work was 


XVI 


unsurpassed in the Beni Suef government. To him I a® 
thankful for the success of the project in that area. 


Dr. Abdel Sarnie Oraran El-Sherif, Director-General of 
Healthy Aswan. Dr. F.l-sherif*s support in Aswan was 
very helpful. I thank him for the many informative 
hours spent together. 


Dr. Mahmoud Yas 
Aswan. Dr. Yasi 
under difficult 
up on the many 
especially appre 


in. Vice-Director-General of Healthy 
n*s support in the fieldy frequently 
conditionsy and his consistent follow- 
aspects of the study in Aswan were 
ciat ed. 


Dr. 


Madowiy 


Director-General 


of Kafr El Sheikh. 


Dr. Rashida Barakaty Parasitologisty University of 
Alexandria. Under her direction the huge task of 
analyzing the thousands of specimens was completed. 
Hard-working and extremely knowledgeabley Dr. Rashida 
epitomizesy to me, the modern Egyptian woman. 

Dr. Ibrahim Faragy Systems specialisty Cairo 
University Computing Center. 

Dr. Noshy MansouTy Parasitologisty Naval American 
Medical Research Unit (NAMRU-3 ), Cairo, Dr. Mansour 
was very helpful with the preparation of the MIFC 
preservation techniguey and provided a mechanism of 
evaluating parasitological results. 

Dr. Gene Hagashiy Immunologi sty NAMRU-3y Cairo. 
Dr. Hagashi was extremely helpful and supportive in 
the development of many aspects of the field study. 

Dr. Merrill Shutty Medical Officery U.S, Embassyy 
Cairo. 


Dr. El-Mumtaz Mubaraky Under-Secretary for Endemic 

Diseasesy EMHy Cairo, 

A very special thanks to Dr. and Mrs. G. White for 
their encouragement throughout this research. Dr. White's 
assistance in providing a mechanism for acquiring funds for 
the analvsis of the data at the University of Michigan was 
greatly appreciated. In this respect I also wish to thank 
Mr. C. Gunnerson of the World Bank for his support and 
understanding in the preparation of this document. I 
appreciate the help of the staff at the Egyptian Academy of 
Scientic Research and Technology under the direction of 
Dr. Hafez. 

There werey as mentioiiedy over ISyOOO Egyptian 

XVI1 


villagers to whom I will be fore 
my appreciation, I can only ho 
study will in some way help 
parasitic infection that is 
population. 


ver frustrated in expressing 
pe that the results of this 
control and eradicate this 
so prevalent in their 


Counterpart to all those 


members here 
Morton S. Hilbe 
aspect of env 
ffiindedness and 
Co-chairing my 
Professor Khali 
teacher and fri 
for his patienc 
involvement in 
was particular! 
Deininger for h 
which a data 
information wo 
Peter Meier for 


at the Univers 
rt was instrume 
ironraental hea 
support have bee 
committee w 
1 H. Mancy. Dr 
end. I am most 
e in reviewing 
the collection a 
y insightful. I 
is assistance in 
set of over 
uld have been 
his enthusiasm 


in Egypt are my committee 
ity of Michigan. Professor 
ntal in guiding me into this 
1th. His continued open-- 
n of the greatest assistance, 
ith Professor Hilbert was 
• Mancy is a most respected 
grateful to Dr. Arnold Monto 
many drafts and whose intense 
nd analysis of the field data 
also wish to thank Dr. Rolf 
computer technology, without 
3.0 million characters of 
overwhelming. thank Dr. 

and assistance. 


I am very fortunate to have a family that has been so 
unselfish in assisting me through my many trials and 
tribulations typically associated with such work. Their 
understanding and confidence provided the necessary strength 
to achieve what seemed impossible. 

This research was part of a joint University of 
Michigan-Egyptian Academy of Scientific Research and 
Technology effort called the River Hile-Lake Nasser project, 
funded by the U.S. Environmental Protection Agency Funds for 
the analysis of the field data at the University of Michigan 
were obtained from the World Bank, contract number 21426. 


XVI11 


CHAPTEH I 


INTRODUCTION 


Disease: Schistosomi asis 


origins of 
lakes reg 
of man’s 


The evolutionary 
stem from the great 
hypothesized cradle 
The host and parasite have over 
to each other and, under natu 
severe widespread infections 
nature of paleolithic man le 
endemic foci of infections to de 


schistosomiasis roost likely 
ion of eastern Africa, the 
ancestors (Bruijning, 1971). 
the eons become well adapted 
ral conditions of the past, 
were unusual. The nomadic 
ft little opportunity for 
velop. 


In the papyrus of Kahun {ca. 1900 B.C.) is found the 
first recorded evidence of haematuria, the classic 
presentation of Schisto som a haematobium. The hieroglyph 
, aaa, 


£ 



- n 

<=u) 


and 




depicted haematuria and its curative magic 
respectively. There are tnirty-nine other remedies 
on the papyri of Ebers, Berlin, and Hearst (Faroog, 


formula, 
recorded 
1973) . 


Egyptian 

directly 


Calcified ova of haematobium were found in 

mummies of the XXth Dynasty (1250-1000 B.C.) , 

demonstrating that this parasitic infection did occur in the 
Nile Valley during the pharonic era (Buffer, 1910). It also 
suggests that the highest attainable social status of that 
period did not exclude one from infection. It is possible 
that schistosomiasis was widespread and constituted a 
serious problem during this ancient time. The discovery and 
classification of the causative trematode (Di stom a 
haematobium) by Theodore Bilharz in 1851 at the Cairo Kasar 
El Aini hospital and the demonstration that Bulinus snails 


1 












were the intermediate host to the infection in man in 1915 
at El Margh village near Cairo (Leiper, 1915), confirmed 
Egypt as the ••home** of schistosomiasis. Indeed, Egypt still 
remains the site most frequently studied by scholars 
interested in this disease, and the Nile Delta is still one 
of the world*s most intense foci of schistosomiasis 
infection. 


L if e Cycle of Schistosomiasis 


Schistosomiasis is a chronic helminth infection in man 
caused by the genus of trematodes Sch istosoma. There are 
three species: S^ hae m atobium ^ S_. mansoni, and S^ lap oni cum. 
Two of these species, S_. haematobium and S^ mansoni are 
found in Egypt and Africa* S^ ^aponicum is restricted to the 
orient. The life cycle of all three is very similar. Each 
ovum (egg) containing a ciliated larva (called miracidium) 
is passed either in human urine (Sj, h aem a tobiu m) or in the 
stool ( S* man soni ) and hatches cn contact with water. The 
freed miracidium can penetrate the appropriate snail host 
but must do so within a few hours or die. The genera 
Bu lin us, Biomphjlaria, and Qaco melania are the respective 
primary snail hosts for 5^. haematobium, S. mans oni, and 
S. jap onicu a. In the snail host, the miracidium becomes a 
sporocyst which replicates asexually to give rise to the 
final larval form, the cercaria. The cercariae, after 
leaving the snail, are capable of penetrating the unbro)cen 
skin of the human host, but will not survive for longer than 
twenty-four hours in water* 

Once in the body, the cercariae reach the portal system 
where they mature into male and female adult worms and mate. 
The eggs are laid and released to the outside via the 
bladder or intestine to repeat the life cycle. The cycle of 
infection from man to snail and back to man can be completed 
in eleven weeks. 

Clinical features of schistosomiasis include fever, 
hepatospenomegaly, eosinophilia, lymphadenopathy, and 
malaise. In haemat ob i um infections, hematuria is common* 
Complications of the genito-urinary tract can lead to 
hydronephrosis. It has been speculated that cancer of the 
bladder results from the calcification of the bladder walls 
where eggs have been deposited. The duration of the 
infection in man has not been firmly established. Viable 
ova have been recovered from persons who have been free of 
exposure for over twenty years, (Warren, 1975) indicating 
that infection, once acquired, can remain for long periods. 
Fe-exposure and reinfection lead to increased worm loads and 
therefore to more severe clinical consequences. The rate of 
spontaneous less of infection was measured by Farooq and 
Hairston (1966) in Egyptian children. For children aged 5 






















and 6 the rate of loss of infection was 0*049 cases per year 

m an s on i had a much higher rate of 
less of infection: 0.327 cases per year. Higher loss rates 
for both species were observed in younger children. 

Exact measures of morbidity and mortality have not been 
made. However^ the relationship between worm burden and 
morbidity is roughly proportional (Cheever, 1968). Severe 
clinical features are seen in only a small portion of those 
who are infected (Farooq^et al^, 1966b). 

The actual role of schistosomiasis as a public health 
problem is not clear. The contribution to mortality is low. 
However, the literature pertaining to the contribution by 
schistosomal infections to morbidity at the community level 
is conflicting {Jordan, 1972). Heviews by Jordan (1972) and 
Warren (1975) on this aspect are available. Nevertheless, 
it has been estimated that over 200 million persons are 
infected worldwide {Weir, 1969), at an annual cost due to 
reduced productivity of over $641 million (Wright, 1972). 


The Se t ting : Egjgpt 


Egypt is made up of several distinct sectors. The 
largest sector is made up of the eastern and western 

deserts, which account for over 90/? of the land mass. The 
area is populated rather sparsely by nomads, with a few 
small settlements. Located in the western desert are 

several more populated oases. El Kharga and El DaXhla 
oases, in what is referred to as the new valley, are sites 
of recent agricultural development and currently have a 
combined population of about 76,000 persons. There are also 
populated settlements along the western Mediterranean 
shoreline and along the Suez Canal. Ninety-nine percent of 
the Egyptian population is compressed in the Nile Valley and 
in the Nile Delta, 3.5% of the country*s land mass. The 
population density in these areas has been estimated at 
2,400 persons per square mile (Waterbury, 1971). For the 
purposes of this study, the Nile Valley has been divided 
into: 

{a) the delta, or lower Egypt, 

(b) Upper-Middle Egypt, between the delta and Assyut, 
and 

(c) southern or Upper Egypt located between Assyut and 
the Aswan High Dam (AHD) , (See Figures 1 and 2). 
Before the AHD was constructed, there existed a 
people, called Nubians, located between Aswan and 
the Sudanese border. When the new lake inundated 
this area, the Nubians were resettled, en masse. 






in Kom Offibo, an agricultural plain about 75 ka 
north of Aswan, and in Kheshm El Girba, in the 
Sudan* 

The population of Egypt has always been predominantly 
’•rural,” described by Scott (1937) as persons ’’whose habits 
of life bring them into contact with fields and canals where 
infestations with parasites may be acquired.” In 1937, 
11.49 million persons were living in a rural setting: 12% of 
the total population of 15.92 million. By 1960, 62% were 
rural. The rural population has further declined to 56.1%, 
according to the last census survey conducted in 1976 
(CAPMAS, 1976). Accordingly, it is estimated that 21.45 
million persons are currently at risk of acquiring the 
infection, assuming transmission in the urban centers is 
nil. This is a relatively safe assumption to make since 
habitats for the snail vectors, i.e. open canals and drains, 
are not found in the urban areas of Egypt. This does not 
mean that urban populations in Egypt are free of 
schistosomiasis infections. New cases of schistosomiasis 
are constantly being brought into the urban areas due to the 
steady influx of rural immigrants who have already acquired 
the disease. 

The distribution of the Egyptian population is as 
fellows: 60% of the population resides in Cairo or north of 
Cairo in the Nile Delta or Lower Egypt, 23% live in Upper- 
Middle Egypt, and 12% live in Upper Egypt (Omran, 1973). 
Males comprise 53% of the total population (CAPMAS, 1976). 


Irr igation# and Schistoso miasi s 


Bruijning (1971) very nicely develops a theme where man, 
emerging as a cultivator in the fertile basin of the 
Euphrates and Tigris rivers, tips the balance of infection 
by schistosomes in favor of the parasite. According to 
Bruijning, even the earliest attempts at agriculture 
included irrigation, and irrigation ditches provided new and 
more favorable habitats for the proliferation of the snail 
vectors. 

The irrigation canals, ditches, or drains, with their 
smaller water volume and sluggish movement, form a sheltered 
environment more suitable for snail growth, compared to the 
irregular and voluminous discharges of the main streams. 
Dilution of cercarial output is reduced in irrigation 
ditches, and man and water are brought closer together. 

Although Leiper (1915) in Egypt was the first to suggest 
the role of irrigation in enhancing schistosomiasis 
transmission, it was Khalil (1927, 1935, 1938), also working 










5 


Figure 1. This is a general map of Egypt in the 1930^s, after Scott 
(1937), and shows the extent of perennial irrigation in the country 
at that time. Now the entire valley is perennially irrigated to 
Aswan . South of Aswan is Lake Nasser, which extends south of the 
border into Sudan. 

















in 


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6 































in Egypt, vho showed conclusive evidence that irrigation 
schemes grossly enhanced transmission. Table 1, taken from 
Khalil’s study, shows the percentage of persons from four 
different villages infected with haematobium in 1934, 
before canals and pumps were installed, and in 1937, about 
three years after installation. Over a tenfold increase in 
schistosomiasis was observed. Villages over one kilometer 
away from the new canals had lower rates than those located 
nearby. The numbers of patients with schistosomiasis at the 
local hospitals also increased dramatically. Prevalence 
remained low in nearby areas which continued the ancient 
"basin’* form of irrigation. 


Table 1 

Effects cf Conversion from Basin Irrigation to 
Perennial Irrigation in Kom Ombo, 

Upper Egypt. After Khalil and Azim, 1938. 



- T- 

1 

1, n- 

Percent 

Positive 

With 

Village 

r 

1 

1 

1934 

T 

1 

- 1 


1937^ 


I 

1 

t 

S. haematobium 

t 

1 

h. 

haematobium 

Sebaiia 

I 

1 

1 

1 

0 

1 

1 


44 

Kilh 

1 

1 

7 

1 

1 

1 


50 

Bimban 

i 

1 

1 

2 

1 

1 

1 


64 

Mansouria 

1 

1 

j 

11 

1 

1 

JL— 


75 


♦Results obtained by examination of urine and stool 
specimens of 100 persons from all classes in 1934 
and three years later after conversion of the area 
to perennial irrigation. 


Basin irrigation predates all other forms of irrigation 
practices and does not create the environmental conditions 
suitable for snail proliferation. Under basin irrigation, 
the low flat lands on the banks of the Nile were flooded 
annually during the late summer. The local farmers 
(fellaheen) would trap the siit--laden flood waters using 
small earthen dikes. After the silt had settled out on the 
land, the water would be released. (This was only a slight 
modification of what occurred naturally.) The fields would 
be planted. This form of irrigation produced one crop per 















year, provided it flooded. Pumps and canals give the farmer 
an obvious advantage, and an impounded reservoir increases 
this advantage. Damaging floods can be better controlled 
and droughts alleviated. With an increase in available 
water, irrigation syistems can be expanded to new lands and 
cultivation continued throughout the year. 

During the last century and early part of this century, 
development programs were instituted in Egypt which included 
telegraph networks, railroads, harbor construction, and 
barrages (dams), Barrages located at Aswan, Esna, Naga 
Hammadi, Assyut, and at the Nile Delta created reservoirs 
for the expansion of irrigation schemes. Previous to this 
period, irrigation was primarily basin. 

Nevertheless, by the 1930*3 the Nile Delta and the areas 
south of Cairo to Assyut {see map. Figure 1) were irrigated. 
Only the governorates of Sohag and Qena, along with parts of 
Aswan were not irrigated with more modern methods. Over 85% 
of the rural population were cultivating land under 
irrigation schemes that posed as sites for schistosomiasis 
transmission. 

The first major perennial irrigation (perennial 
irrigation means year-round irrigation and has been the term 
used for irrigation other than basin) scheme, built during 
the latter part of the last century was located between the 
two branches of the Nile, the Eosetta and the Damietta, in 
the Nile Delta. It was a huge scheme involving the 
construction of an elaborate maze of canals and drains. 
Soon after its completion, the delta began producing its 
famous long staple cotton. Apparently the digging of the 
canals and drains took a brutal toll on the local peasantry. 
Thousands reportedly died, and where there presumably had 
been only very low levels of schistosomiasis infection, 
Scott (1937) found in the 1930*s that over half the 
population in the Nile Delta was infected, and that in many 
areas the prevalence was over 90%. This apparent increase 
was quite dramatic and all subsequent attempts have failed 
to eradicate schistosomiasis. Lenoix (1958) elaborated on 
the relationship between irrigation engineering, the 
impoundment of streams, and schistosomiasis. Methods for 
controlling snail growth were suggested. Farooq (1966a) has 
shown evidence obtained from field studies in Egypt 
suggesting that the type and size of irrigation water 
courses and the proximity of the irrigation watercourse to 
the village are important factors in transmission. It was 
further suggested that the two different snail vectors, 
Buli nus and Biomp h alari a, favored different types of 
irrigation watercourses indicating that transmission of 
these two species of schistosomes occurs separately. 

Impounded reservoirs, often indicated for irrigation 
expansion, also create new environmental conditions suitable 


/ 


y 





for snail vectors of schistosoaiiasis to flourish. The 
shoreline frequently provides conditions similar to the 
sluggish waters of small irrigation canals and drains. The 
more convoluted the shoreline^ the better. 

It should be clear by now that the construction of the 
ABC and the formaticn of the Lake Nasser Reservoir, now 
approximately 450 kilometers long, could conceivably spread 
the snail vectors of schistosomiasis into the new habitats 
created by the dam and the related irrigation expansion, 
and, with them, the disease. Environmentalists, 
epidemiologists, and parasitologists have foreseen this 
problem. Evidence cited below from other man-made lakes 
supports their view, 

Hira (1969) and Webster (1975) reported that 
schistosomiasis was low in the indigenous populations living 
along the 'Zambesi River in central Africa, Following 
construction of the Karbia Dam on the Zambesi and the 
filling of Lake Karbia, Hira (1969) found increased 
prevalence of schistosomiasis at several lake-side villages. 
In school children, 68,8% had become infected. Overall 
prevalence as high as 58% was noted. 

In Ghana, McDonald (1954) outlined potential medical 
problems that could arise from the formation of Lake Volta, 
the world’s largest man-made lake. Snail vectors were 
absent in the area to be inundated. Now, Obeng (1975) 
reports that the snail vectors are common in many places 
along the shore and that transmission is increasing, 
McDonald’s concern was that eradication of snail 
populations, once they became established, would be 
difficult, if not impossible, due to the vast area of the 
lake. 


The Kainji Lake in Nigeria has also created environs 
conducive for schistosomiasis transmission. Snail vectors 
were present before dam construction (Iraevbore, 1975) but 
the extent to which the tribes living in the river valleys 
of this area were infected is not known. (Unfortunately, 
this is a typical situation in many tropical developing 
areas.) Dazo and Biles (1970) studied the resettlements 
located on the periphery of Lake Kainji, Nigeria and 
reported that 31% were infected. Follow-up studies a year 
later (Dazo and Biles, 1971) indicated that transmission was 
increasing. Similar findings have been made by Harinasta et 
al. (1972) at Norn Pong lake in Thailand, indicating that 
this is a problem of the tropics in general and not limited 
to Africa. 


9 


The Controversy 


Armed with the knowledge that dams and irrigation 
schemes in Africa and in other tropical regions create new 
habitats for snail vectors, scientists and news reporters 
alike attacked the AHD as a potential disaster. The results 
of the project, it was speculated, would cause an 
astronomical increase of the disease in the population. The 
cost of this disastrous increase would negate any benefits 
of the project, namely the increased conservation of the 
water resources of the Nile and hydroelectric power. Van 
der Schalie {I960, 1963, 1972, 1974) repeatedly expressed 
grave doubts about the AHD project. In one article, 
evidence was presented that schistosomiasis had increased 
roughly seven-fold, and that this increase was the direct 
result of the AHD (Van der Schalie, 1974). These data, 
referred to by Van der Schalie, were collected by Dazo and 
Biles (1971) and are reviewed in the following section- 

Faroog (1967) estimated that half of the population 
was already infected, i.e. 14 million infected of a total 
population cf 30 million in 1967. In areas that were to be 
converted or reclaimed, Farooq expected the prevalence to 
increase from 5% to 70%, and calculated that 2.65 million 
new cases of schistosomiasis would result after the 
completion of the AHD project. Scott (1969) , whose studies 
in 1937 were the source of Farooq's (1967) estimate, 
suggested that there would be at least one million new 
cases, but added that predictions as high as six million new 
cases had been made. Ayad (1966) warned that 
schistosomiasis would increase in the areas that were to be 
converted to perennial irrigation following the construction 
of the AHD. Heyneman (1971), in a general article on ”mis- 
aid” to the third world, indicated that impounding the Nile 
had directly resulted in the spread of schistosomiasis in 
Egypt. Fogel, et. al., (1970) estimated that 60% of the 
population of fgypt would become infected in the early 
1970*s as the AHD complex was completed. Furnia (1975) 
stated that schistosomiasis was more prevalent now than ten 
years ago, "having been exacerbated by an increase of placid 
waters from the increased irrigation canals and Lake Nasser 
resulting from the high dam at Aswan." Carter (1969), 
McJunkin (1970), and Farid (1975) reiterated previous 
speculations. In the Cecil-Loeb textbook of medicine, Lewis 
(1971) says. 

Irrigation schemes may have serious ecologic 
consequences for the public health. In Egypt, 
schistosomiasis has always been endemic, not made 
worse by seasonal flooding of the Nile. But in areas 
of perennial flooding, such as in the delta, there is 
total infestation of the population. With the new 
Aswan Dam, there will be large new areas of perennial 



flooding, which may greatly increase the spread of the 
disease• 

Sterling (1972), writing in the popular press, is 
probably the one most responsible for bringing the "Aswan 
High Dan disaster” to the attention of the general public. 
Numerous news media articles have since appeared and, 
without fail, blame the AHD project for Egypt’s 
schistosomiasis problem. 

However, among all of the speculation, no mention was 
made in any context of the impact of the AHD project on the 
Egyptian Nubian population. Indeed, this is a small group, 
and this is perhaps the reason that the Nubians have been 
overlooked. Nevertheless, it was the Nubians who were the 
ones most directly and immediately affected, because these 
people lived in the Nile Valley south of Aswan, and had to 
be relocated before the lake began to fill. The original 
homes of the Nubians are now inundated by Lake Nasser. What 
was the prevalence of schistosomiasis before the Nubians 
were moved? What is the prevalence now that they have been 
resettled on a perennially irrigated agricultural plain, 
called Koa Ombo, just north of Aswan? 


Rese arch Objectives 


The intent of this study is to assess the role of the 
AHD project on schistosomiasis transmission in rural Egypt 
and in the Nubian population. In order to do this, it was 
imperative to collect any and all available and frequently 
not-so-available pre-AHD information on the prevalence, 
distribution, and incidence of schistosomiasis in Egypt. A 
review of this kind has not been prepared since Scott’s 1937 
work, now ^Q years out of date. 

More specifically the present study aims to: 

1) assess the status of schistosomiasis and related 
environmental health factors in the populations at 
risk, i.e. the downstream rural population and the 
Nubians, 

2) show, using historical data and experimental 
results collected on prevalence, distribution, and 
incidence of schistosomiasis, the changes in the 
epidemiology of this parasite in typical rural 
sites downstream and establish secular trends, 

illustrate the effect of irrigation practices, an 
important environmental variable, on the spatial 
and temporal distribution of schistosomiasis, 

n 


3 ) 




4) evaluate the role of village water supply in 
schistosomiasis prevalence and the impact of this 
parameter and other environmental parameters on 
transmission, 

5) demonstrate the relationship between certain 
aspects of population dynamics and the spread of 
schistosomiasis in the rural sites^ and 

6) suggest future needs for surveillance and control 
strategies for this disease. 

This study^ by comparing current data amassed in Egypt 
with historical data, is designed to detect changes in 
schistosomiasis prevalence and distribution that may have 
been produced by the presence of the AHD complex. The rural 
populations living downstream from the AHD were analyzed 
separately from the Nubian population. 


The Review of 
past survey inforraa 
accomplished in the 
schistosomiasis sur 
baseline for establ 
Thus, it is an inte 


literature in the next chapter analyzes 
tion in Egypt, It shows what has been 
past, it points to current needs in 
veillance in Egypt, and it serves as a 
ishing changing patterns of transmission, 
gral part of the design the study. 


12 


CHAPTER II 


REVIEW OF LITERATURE 

Introduction 


This review is a survey of all material, published or 
unpublished, from which data could be obtained on 
prevalence, distribution, incidence, or any facet of 
schistosomiasis transmission in Egypt, It includes the 
earliest material, dating from the 1800*s, Frequently, 
historical data of this type on Egypt were unavailable at 
the University of Michigan and thus had to be acquired in 
Egypt, there is almost a total lack of data on pre-dam 
health conditions and information in other developing 
countries similar to Egypt where huge man-made lakes have 
been created or are currently being built. This unfortunate 
situation is stressed because dams are being built at an 
accelerated pace, and without knowledge of pre-dam health 
conditions very little measure of the impact of these 
projects on human health can be made (Waddy, 1966; 
McDonald, 1958; Standly and Alpers, 1975) . 

Obtaining historical data in Egypt poses its own 
problems; thus for the interested worker resource centers in 
Egypt have been listed in Appendix 1 as an aid to speed the 
preparation and documentation necessary to establish 
research needs, design, and priorities that are required 
before work can begin. Several important articles 
pertaining to this study were found in the Journal of the 
Egypti an Public Hea lth A ssoc iation, This journal has a 
very limited circulation in the United States, and is not 
indexed. Often individual issues were without a table of 
contents. It was only by perusing the entire set of more 
than 40 volumes, article by article, that important and 
contributing historical data were located. Indeed, this 
review, prepared originally in Egypt, constitutes a research 
endeavor in itself. As pointed out in the Introduction, the 
data reviewed in this section provide a baseline for 
establishing patterns of schistosomiasis transmission before 
the AHD was built. Therefore, an analytical assessment of 
this background data was necessary. Basically, an 
evaluation of the methodologies used by the different 
studies reviewed was made in order to highlight comparisons 
between different studies. Because of serious 


13 






methodological differences^ some historical sources had to 
be completely discarded as baseline sources, but 
nevertheless are included here for completeness. 

It is remarkable that at this time no long-range 
policy exists that would serve as an outline of needs for 
research activities concerned with surveillance, prevention, 
or control of schistosomiasis in Egypt. Furthermore, no 
recent comprehensive assessment of past data on the 
occurrence of this disease exists from which strategies 
could be formulated. No overview of the extent or expected 
trends in schistosomiasis infections in Egypt has been 
prepared. To guote Omran, et al^ (1962) , ”The use of 
epidemiological methods in Egypt has been so fragmentary and 
so disorderly applied that a large amount of data, which 
could have been collected, was missing. Collection, 
analysis, publication, and circulation of knowledge are far 
from being satisfactory.” 

It is hoped that this review will provide a basis for 
a more rational development of future work, and the problems 
referred to by Omran,et a l . (1962) minimized. An inventory 
of historical data has been prepared and respective authors 
classified in a master chart. Table 2 is a list, by author, 
area, and date of publication, of works in which available 
prevalence information has been reviewed. 


W ork on th e P revalen ce of Schis to som iasis 


Haematuria has always been common in Egypt. It was 
seen in the French armies led by Napoleon after the invasion 
of Egypt in the early 1800*s. In the late 1800*s, a number 
of hospital patients in Cairo were surveyed for 
schistosomiasis, and one-third were found infected. Between 
1900 and the late 1930*s, different surveys were carried 
out, mostly in the northern areas of Egypt, with different 
findings depending on techniques and analyses used. Table 

3, taken from Azim«s review (1935), cites these different 
investigators and their respective findings. Azim included 
his findings of a survey in the Nile Delta, shown in Table 

4. These results were based on the number of individuals 
positive for either h aemato bium or Sj^ manso ni in groups 
of 200 persons selected from each village listed in the 
table. The results showed that both forms were common. 
Azim (1935) also surveyed areas south of the delta where 
perennial irrigation had been installed. As shown in Table 
5# found, and at high rates, similar to 
those in the delta. 

None of the findings cited in Azim*s (1935) review are 
comparable, and the lack of methodological information 
render them inconclusive. Nevertheless, it seems apparent 

14 












Table 2 

Suaraary of Prevalence Surveys for Bilharziasis in Egypt, 

by Area, Year, and Author 


Area of 
Survey 

“T 

1 

1 Year 

■T" 

1 

1 

f 

Author 

Country-wide 

1 

1935 

1 

Scott 

Country-wide 

1 

1955 

1 

EMPH-Nright 

Nile Delta 

1 

1 1866 

-1935 

1 

1 

Azim 

Calyubiya 

1 

1936 

1 

Khalil and Azim 

Qalyubiya 

1 

1952 

1 

Weir 

Qalyubiya 

1 

1954 

1 

Chandler 

Qalyubiya 

1 

1956 

1 

Dimmette 

Qalyubiya 

1 

1958 

1 

van der Schalie 

Calyubiya 

1 

1959 


Abdallah 

Iflaka 

1 

1963 

1 

Sherif 

Eeheira 

1 

1966 

1 

Farooq, et al. 

Eeheira 

1 

1966 

1 

Bell, et al. 

Kafr El Sheikh 

1 

1972 

1 

Hussein 

Eeheira 

1 

1973 

1 

Gilles. et al. 

Qalyubiya 

1 

1 

1977 

1 

1 

Alamy and Cline 

Upper-Middle 

1 1866 

-1935 

\ 

1 

Azim 

Giza 

1 

1949 

1 

Khalil 

Giza 

i 

1955 

1 

Zawahry 

Assyut 

1 

1968 

1 

Hamman 

Giza 

1 

1970 

1 

Abdallah 

Eeni Suef 

1 

1972 

1 

Hussein 

Fayoum 

1 

1976 

1 

EMH 

Giza 

1 

x 

1977 

1 

Abdel-Salam and Abdel-Fattah 


Table Continued 


that the prevalence of both foras of schistosomiasis was 
high in the northern delta and that S,haematob ium prevalence 
was high in the perennially irrigated areas of the south. 

The association between the perennial irrigation 
systems and the spread of schistosomiasis was first clearly 
demonstrated by Khalil and Azim (1935) in Kom Orabo in Upper 
Egypt during this same period, as mentioned in the previous 
section. No ma nson i infections were seen by the workers 
in this region of Upper Egypt. 


S chis to somias is in Eg yp t 


A brief view of the data for the country as a whole is 

15 

















Table 2 
Continued. 


Area of 
Survey 

1 — 

1 

1 

Year 

T 

1 

1 

1 

Author 


1 

1 


T ” 
1 


Upper Egypt 

I 

1 

- 

1 

1 

— 

Korn Ombo 

1 

1935 

1 

Khalil and Azim 

Sohag 

1 

1954 

1 

Nooman 

General 

j 

1955 

1 

EM PH 

Aswan 

1 

1966 

1 

Tuli 

Aswan 

1 

1970 

1 

Satti 

General 

I 

I 

1972 

1 

Dazo and Biles 

Old Nutia 

1 


1 

1 


General 

1 

1951 

1 

Dawood 

General 

1 

1958 

1 

Bifaat and Nagaty 

General 

1 

1964 

1 

Zawahry 

New Nubia 

1 

1 

• 

1 

1 


General 

1 

1972 

1 

1 

Dazo and Biles 

Lake Nasser 

] 

j 


1 

1 


Fishermen 

1 

1970 

1 

Satti 

Fishermen 

1 

1971 

1 

Dazo and Biles 

Fishermen 

1 

1972 

1 

Dazo and Biles 

Fishermen 

1 

1974 

1 

Scott and Chu 

Desert Areas 

1 

1 


1 

1 


Dakhla Oasis 

1 

1952 

1 

Abdallah 

Dakhla Oasis 

1 

1957 

! 

Azim 

Dakhla Oasis 

1 

1957 


Bifaat, et al. 

Dakhla Oasis 

1 

1964 

1 

Hifaat and Nagaty 

Wadi El Natrum 

1 

1964 

1 

fiifaat, et al. 

Mersa-Matruh 

1 

1 

1964 

1 

J 

Sif aat 


followed by a more detailed review of information available 
for each of the following sectors: the Nile Delta, Upper- 
Widdle Egypt, Nubia, Lake Nasser, and the Desert Sectors 
(which have been grouped together)• 


Country Wide Prevalence Surveys 


Only two surveys have been carried out in Egypt which 
sampled the entire country, excluding Nubia, Lake Nasser, 
and the Desert Areas and are comparable. The first was 
completed in 1937 by J* Allen Scott, and the second was 
completed in 1955 by the Egyptian Ministry of Public Health 















Surveys of Uilharziasis Completed Between 1866 and 1924 in Egypt 

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Table 4 

Prevalence of Bilharziasis in the 
"iile Delta in 1935* 

After >1. A, Azim, 1935 


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*This table indicates that the ova of _S_, ®,ansoni appear with a limited 
frequency in the urine^ and the reverse can be seen for ^ haemat obiu m in the 
stool* Results are from the examination of 200 persons at each village. 


















Table 5 


Prevalence of Bilharziasis in Areas 
South of Cairo. After Azin (1935), 


Village 

Percent Positive 

Bith 

S. haematobium 

S. mansoni 

Oussim 

69 

0 

Kafr Aiiar 

73 

0 

Bolida 

71 

0 

Abahaway 

70 

3 

Senouris 

69 

4 

Kosm Abo Radi 

71 

12 

Ashmant 

60 

0 

Beni Bekhit 

70 

5 

Dashut 

80 

17 

El Pant 

61 

17 

Kefour 

72 

12 

Sheikh Fadl 

60 

8 


(EMPH^ later to becoae the Egyptian Ministry of Health and 
to be referred to as EMH) and was reviewd by Bright (1973). 
In 1965 a third study was completed by the EMPH^ but the 


results are 
methodology 
Following a 
details of 
appropriate 


of limited value due to the differences in 
between this study and the previous two. 
general review (See below) of these two surveys, 
these studies are elaborated on under the 
geographic subheading to illustrate points 


pertinent to the particular locale 


In 1937, Scott (1937) reviewed the previous studies 
and completed the first country-wide survey. Some 40,000 
individuals were examined on a random house-to-house basis. 
Scott (1937) supplemented these data with results collected 
from over 2,000,000 examinations made at government 
treatment centers. In summary, Scott (1937) found that 60% 
of the population was infected with both forms and 83% with 



















either one or both forms in the north and eastern sectors of 
the Nile Delta. In the south central delta, 60% were 
infected with h aenatobiu m and 6% with ®§IIsoni. In 
Middle-Upper Egypt, in areas under perennial irrigation, 60% 
of the population was infected with lljemato^^m, and in 
those areas in Upper Egypt under basin irrigation, only 5% 
of the population was infected with S_. haematobium. Figures 
3 through 5 are maps showing the distribution of 
schistosomiasis according to Scott. l^nsoni had a 
distinct and limited geographical distribution in the delta, 
and S_. prevalence in the area south 
of Assyut but generally high elsewhere. By 1937, in the area 
north of Assyut (Upper-Middle Egypt) perennial irrigation 
schemes had been constructed and were by far the most 
predominant method of cultivation, as in the delta. In the 
area south of Assyut (Upper Egypt), the older method of 
basin irrigation was still the most common type practiced. 
The association of irrigation practice and prevalence of 
schistosomiasis found by Scott (1937) reinforced Khalil and 
Azim^s (1935) observations. later, Noomaa, ^ al. (1974) 
also found an increase in prevalence of S^ haema tob ium, from 
5.6% to 71.6%, in an isolated area of Upper Egypt which had 
been converted from basin to perennial irrigation. 

It is clear that by the late 1930*s schistosomiasis 
was quite widespread in Egypt. Indeed, in the Nile Valley 
north of Assyut the prevalence of schistosomiasis in the 
population had no doubt reached a peak by this time. The 
conditions were ideal for transmission, as control programs 
did not yet exist (Farooq, 1973). The only aspect not 
clearly understood was, ”Hhy was j_. mansoni only located in 
the northern and eastern delta, and not parallel in 
distribution to ha ematobiu m?** 

Scott (1937) summarized his findings nationwide to 
show that 47% of the population, which at that time was 
about 15.23 million people, were infected with either one or 
both forms of schistosomiasis. He considered this to be a 
very conservative estimate. He further pointed out that the 
population living in the area between Assyut and Aswan, 
estimated at just over 2 million, would come under 
increasing risk of being infected as plans had already begun 
to convert the area to perennial irrigation. 

By 1955, the EMIH completed a follow-up to Scott»s 
work (1937) using the same sampling and laboratory methods. 
The villages selected were also the same sites studied by 
Scott (1937) twenty years before. Some 124,253 persons were 
examined, more than three times the sample population 
examined by Scott (1937). Bright (1973) has reviewed the 
1955 findings and compared that data with the 1937 data, as 
shown in Table 6. It is clear that: 


(a) a fall in 


the 

20 


overall prevalence 


of 
















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22 


Figure 4. A map of Egypt showing the prevalence per 100 of S. haematobium 
among rural persons examined at their homes by Scott (1937). 


























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23 


by the EMPH traveling hospitals and the spots are results of Scott 
(1937). 






















S« haematobiu Bd# from 4 8% to 38% ^ 

roansoni^ from 32% to 9%, occurred between 1935 
and 1955/ 

(b) the decrease in prevalence of ®^§2nl 

consistent for all infected northern provinces^ 
and 

(c) while the overall prevalence of haematobium 
had decreased^ there had been significant, even 
alarming increases south of Assyut in Suhag. 

The results of the 1955 survey do not include the 
number of those persons with mixed infections and thus the 
total prevalence of schistosomiasis, or all those infected 
with either one or both species of S chist o som a cannot be 
calculated from this data* It is unfortunate that the design 
of the survey did not include this aspect* Those infected 
with both species of S chistoso ma should not be ignored for 
it is this group which bears the greatest burden of 
morbidity and mortality (Scott, 1937)* Halawani (1957) 
attributed the decline in prevalence from 1937 to 1955 to 
government anti-bilharziasis campaigns which, he pointed 
out, began in earnest in 1942* 


Schistosomiasis in the Nile Delta 


In 1936, Khalil and Azim (1936) showed both 
S * haematobium and S^ manson i prevalence to be high (55% and 
59%, respectively) in a site 25 km NE of Cairo in the Nile 
Delta* A 4% sample of the population was selected and 
divided into two groups, depending on whether the selected 
individual was working near the village canal in the east or 
not near it in the west. Those working near the canal had 
somewhat higher prevalence of S^. mansoni than those not 
working near the canal. No difference was seen in 
prevalence of haem atobium between locations. 
Considerable differences were noted between sexes for both 
species, the males having the higher rates. 

In 1952, Neir, et al_. (1952) , under the auspices of 
the E«PH and the fiockefeiler Foundation, completed an 
intensive four-year study on the health and sanitation of 
the village of Sinbis, Qalyubiya Province, in the south 
central delta. In the course of the survey, the entire 
population, some 4,232 persons, was examined. An evaluation 
of the housing standards, water supply, fly control, 
latrines, and refuse disposal was made of the entire 
area. Data collected included the presence of lice and 
fleas, diseases of the eyes, nutritional status, vaccination 
status, serological examination for syphilis, enteric 
fevers, tuberculosis, malaria, and an examination of stools 
















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26 


the 1935 rejuits the number examined was 15208 and for the 1955 results, 
'^0978. In the vjovernorates from Fayoum south, stools were not examined for 
S. mansoul ova. 


































and urine for parasites, High prevalence for both forms of 
schistosomiasis was founds 38.4% for haemato biu m and 

12.5% for aansoni. Furthermore, on reexamination of a 
subsample, Weir found an even higher proportion of the 
population, 88%, to be positive for haema to bium . This 
alarming demonstration of false negatives resulted from a 
change in methodology by Weir in the screening for 

haematobium . Routinely, haematobium is detected by 

an examination of the urine for characteristic ova. This is 
done simply by collecting the urine in a conical flask, 
allowing it to sit for a period of about half^an-hour, then 
examining the contents of the sediment by low power light 
microscope. The ova have a higher specific gravity than 
urine, and, if present, will be concentrated in the bottom 
of the flask. Because of the ease with which this test can 
be employed, it has been widely used. 

Two methods were used to produce the increase in 
positives. In one of these, the urine was first 
concentrated by centrifugation and the sediment suspended in 
water, followed by projection of the specimen on a screen to 
search for hatched miracidia. In the second, rectal 
scrapings from each individual were examined for the 
presence of ova. The rectal scraping method of examination 
was found to be far superior in revealing infections. It is 
unfortunate that this method does not lend itself to mass 
screening procedure. 

The implications of Heir, et ali*s (1952) 

demonstraticn of large numbers of false negatives are that 

1) all the previous surveys had underestimated the 
prevalence of haemat obium# and 

2) when the simple sedimentation technique is 
employed an estimate of probable false negative 
error should be included in the results. A whole 
new light is thrown on Scott*s (1937) estimates. 
Presumably the prevalence should be increased in 
areas from 60% to 80%. Certainly no less than 
half of the population was infected in 1937, when 
Scott*s (1937) results were published: over 7.6 
million in a total population of 15.2 million 
persons. 

Weir, et al_.*s (1952) study also suggests that 
S. mansoni was invading a new territory. A careful look at 
the maps In Figure 5 shows that in 1937 S. mansoni was 
almost non-existent in the south central area of the delta 
in which the village of Sindbis is located. Heir, et 
al. (1952) however, found a prevalence of 12.5%. Scott's 
highest prevalence found for the same area was only 7%, but 
it was usually much lower and frequently zero (1937). No 

data were collected for Sindbis itself by Scott (1937) in 

27 









1937, and, therefore , it is possible that the area could 
have been an isolated focus, or, even more remotely, an 
extension of infection from the not too distant south¬ 
eastern sector where ^ mans oni was more common. A more 
likely explanation is that the higher prevalence of 
S. m anson i in Sindbis was the result of differences in 
technique by the surveyors. The rectal scrapings technique 
certainly would have reduced the number of false negatives, 
as compared to the more routine methods of examining the 
stool directly for m anson i ova as used by Scott (1937). 
Apparently Weir, ^ al^ (1952) employed the rectal scraping 
technique only for haem atob ium detection (although it can 
be used for mansoni as well) and, like Scott, relied on 
the traditional method to screen for S^ manso ni. A 
prevalence rate of 12%, therefore, may be too high to be 
explained just by differences in techniques. 

Chandler (1954) carried out a follow-up on Weir, et 
a j. *s (1952) study two years after its completion and found 
that the mass chemotherapy program implemented by Weir had 
reduced the prevalence of schistosomiasis to isolated cases. 
It is doubtful, however that the prevalence continued to 
remain low. Treatment does not reduce the risk of 
reinfection. Indeed, this has been one of the major 
frustrations of treatment control programs, i.e., after a 
course of treatment has been finished, it has been difficult 
to keep the cured patient free from the readily accessible 
snail-infested canals and drains. 

Table 6 includes the results from the 1955 HMPH study 
for the delta sector and compares them alongside those of 
Scott’s (1937) study. A decrease in S_. hae matobium 
prevalence from 57% to 45%, a proportional drop of 12%, can 
be seen for the delta. Decrease in prevalence is seen to be 
greater in some governorates than in others. For example, 
the decline was much greater in Qalyubia than in Gharbiya. 
What is remarkable is the very uniform decrease in 
prevalence for ^ ma nsoni for all governorates in the delta, 
except in Minufiya, which was low to begin with. 

Dimmette (1956), in a study to detect neoplasms of 
the bladder, found 31.7% infected with ^ hae matobium in a 
sample taken from the Qalyubiya Province census, which 
agrees remarkably well with the 1955 EflPH results. 

Qalyubiya was also the site for two other projects carried 
out between 1953 and 1959. In a review of these projects, 
Abdallah (1973) reports that Helmy from the EMH found that 
before treatment 44.5% of the population was infected with 
ha ematob ium and 2.6% with S_. mansoni. Treatment with 
tartar emetic reduced the figures to 30.4% and 1.1%, 
respectively, over a period of five years. The second 
project was a joint American/EMH effort by Berry and 
Halawani (1973) and was designed to assess mollusciciding 
only as a method of redurring schistosomiasis infection. 

CO 











Only children bet¥een 6 and 19 years of age were 
examined. haematob iu ia was reduced from 40.211 to 2 4-211, 

reduced from 515 to zero during the eight- 
year period of the project. 

It should be pointed out that prevalence of shedding 
of ova in the 5- to 9-year-olds is never the same as the 
prevalence in the general population, which is generally 
lower. This is true for both forms of schistosomiasis and 
is irrespective of the seasonal pattern of transmission 
(Farooq^ et al^, 1966)• The age-specific distribution for 
schistosomiasis in endemic areas has been shown to be very 
characteristic. Figure 6 shows the sex-adjusted age- 
specific prevalence curves for four different surveys. The 
same pattern is shown in each one. The prevalence rises 
quickly in younger children, falls sharply in the teens, and 
then falls more gradually thereafter and generally levels 
off at a much lower rate in middle age. The younger groups, 
therefore, provide a more sensitive measure for control 
assessment, as they are the age group most frequently 
positive. Generally, prevalence differs according to sex, 
with males leading, especially those occupied as farmers or 
boatmen. Therefore, crude unadjusted data may differ by 
area depending solely on the structure of the population. 
For example, the prevalence may be artificially depressed in 
an area with more women, all other things being equal. 
Generally, this is not a problem in Egypt, because of the 
similarity of composition in the rural populations. 

There is an exception. The population in Aswan and 
Nubia has a low lale;female ratio resulting from male 
emigration to the northern cities for employment, leaving 
behind the adult females and children. This has been a 
continuous migratory pattern since the turn of the century. 
Currently, the trend has changed somewhat to moving the 
family nucleus as well. Labor demands from neighboring Arab 
countries contribute to the depressed ratio. Therefore, in 
this area crude rates might underestimate true prevalence. 

Wright (1973) reviewed the results of urine 
examinations on 60,197 persons, which are shown in Table 7. 
The survey involved 23 different villages in various 
locations in Egypt to show the age-sex specific prevalence. 
This was a companion field study to the 1955 EMPH survey. 
Prevalence in males was slightly higher than in females and 
reached a maximum at 10 to 14 years of age. Both males and 
females showed the typical increase in prevalence during the 
early years, reaching a peak in the teens and tapering off 
after the early twenties—the classic age-sex distribution 
of schistosomiasis in Egypt. 


Sherif (1968) 
in Iflaka. Iflaka 
north western delta, 


found somewhat higher prevalence rates 
is in the Beheira governorate in the 
where ^ mansoni is also found. Sherif 

29 



Figure 6. The prevalence o£ schistosomiasis in four surveys. 
After Omran (1973). 


30 










(1968) detected 63,2% with haematobium^ 60.6% with 

§-s f§S§oni, and 82.2 with either one or both; and termed the 
area ”hyperendemic. ** These prevalence figures suggest a 
sharp increase since the 1955 EMPH studies for this area 
(see Table 6)• Possibly Iflaka was an atypically high 
prevalence site^ again reflecting the 
distribution of schistosomiasis. Another 
such an increase may be the result of 
methodology. It is difficult to determine the exact 
of the differences based on the information available. 


highly focal 
explanation for 
differences in 
cause 


in the study^ as was 
for schistosome ova. 
from four different 


In 1966, also in the Beheira governorate, west of the 
IflaXa area, one of the most comprehensive studies of 
schistosomiasis in Egypt was completed. This was the joint 
WHO-UNICEF-ff9H ”Egypt-49” pilot ccntrol project, directed by 
M. Farooq (Farooq and Kielsen^ 1966). Approximately 5% of a 
total population of 250,000 persons were examined. Socio¬ 
economic, environmental, and cultural factors, as well as 
domestic water habits, were included 
the examinaticn of urine and stools 
The sample population was selected 
sectors or divisions: rural, reclamation, urban^ and 

ccntrol. The control sector served as a comparison site for 
the others in which measures against schistosomiasis were to 
be tested. Prevalence for one or both forms was high in the 
control sector (59.5%), in those who were occupied as 
farmers (50.6%), boatmen and fishermen (60.4%), in males in 
the 10-14 age group (84.4%), in those who could neither read 
ncr write (32.2%), in those who swam (61.9%), in those who 
washed clothes and utensils in canals (50.2%), in those who 
lived in mud or mud brick houses (46.4%), and in those who 
did not have piped water (53%). The relationships between 
schistosomiasis prevalence, regardless of type, and the 
different independent variables follow very closely what 
might be expected, i.e., those who have most water contact, 
who are less educated, who have inferior housing, and who 
use the canals as a drinking and washing water source have 
higher prevalence rates than their counterparts. It was 
also expected that those who had latrines in their homes and 
used them would have lower rates (32.5%), than those who did 
not have latrines in their houses (47.9%). In addition, 
these results show that by far the lowest prevalence was 
found in these persons who have latrines in their houses but 
did not use them (10.8%). This somewhat surprising 
observation was found consistently throughout the project 
area in each divisicn. A further analysis based on subject‘s 
age and type of house showed that the non-users were often 
very young children whose rates for schistosomiasis were 
generally low anyway. Age, however, was not the determining 
factor for mud brick or inferior houses for which the rates 
were again the lowest for those who had latrines and did not 
use them. In this analysis, the difference in prevalence 
between having a latrine and using it and not having a 

latrine was very small, and for the poorer housing, not 

31 




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significant. No truly satisfactory answer was provided. 

It would have been worthwhile to examine the method in 
which the use or non-use of a latrine was determined. No 
elaboration of this method was available in this article. A 
definition must precede the formulation of the question^ 
since observation seems unlikely, and it is this definition 
that must be analyzed, as well as the data. Results are 
directly affected by the methods with which they are taken, 
and without knowing the methodology employed, interpretation 
is difficult. 


Another interesting relationship shown by Farooq, et 
aj. . (1966) was that between the age, sex, and swimming 

habits, and the prevalence of schistosomiasis. Infection 
with both species was twice as great among frequent swimmers 
as among non-swimmers. Much higher rates for swimmers were 
consistently found for either species or for schistosomiasis 
in all four divisions of the project area. Of the males who 
swam, 57.3% were between the ages of 5 and 19, and 53% of 
the female swimmers were between 5 and 14- Male swimmers 
outnumbered female swimmers four to one. The overall higher 
rates in young swimming males strongly 
group's activities play an extremely important role 
continued transmission of schistosomiasis in Egypt. 


suggest that this 

in the 


Figure 7 shows the similarity of the age-specific 
prevalence for the different forms of schistosomiasis in the 
four different project divisions, again demonstrating the 
characteristic and universal pattern of high rates in the 
young and lower rates in the adults. ”Bilharziasis” in this 
figure refers to those who are infected with one or both 
species of schistosomes and, as pointed out before, is 
synonymous with the term schistosomiasis, 
project area 29.7% had ^ haematobium 
Sj Prevalence of mixed infections 

with both) is always less than 
•’fcilharziasis”. In the overall 
S. haematobium and manson i, 
or biiharziasis. These results 


In the overall 
and 28.5% had 
(those infected 
for either of the two or for 
project area 17.2% had both 
and 40.9% either one or both 
are summarized in Table 8. 


Significant differences were noted in the Egypt-49 study, 
not only between divisions, but also between villages, as 
well as between different parts of the village. 

Even more recently, in the north central delta and in 
Middle Egypt, a project on health manpower sponsored by WHO 
and the High Institute of Public Health (Alexandria 
Oniversity) completed a survey in 1972 which included a 
measure of prevalence on several human parasitic infections. 
(Hussein, 1972). The sample population was selected 
systematically from a frame or list of all families in each 
of five villages in an area near the town of Kafr El Sheikh. 
Some 4,177 persons were selected, of which 13.4% were 

positive for S^ haem at obium ova in the urine and 15.4% 

3 3 













“ Bilharziasis ’’ 
S. mansoni 

S. haematobium 
Mixed infection 


Figure 7. Age prevalence distribution of schistosomiasis in the 
Egypt-49 project area and in its four divisions. After Farooq, 
et al. (1966). 


34 



































Corrected Estimated Prevalence of Bilharziasis in the 

Project Area by Division* 


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positive for manso ni ova ia the feces (about 8% did not 
give a specimen). Tai)le 9 shows the age-sex distribution of 
S-s hae ma tob iu m and mansoni infection in the selected 
population. Infection with either species followed a 
typical distribution with slightly higher prevalence in the 
males* 


These findings are the lowest in prevalence so far 
seen for this area of the delta. If those individuals who 
did not give a specimen had been positive, then the 
prevalence would have increased to 20% and 23% for 
S. haematobium and mansoni, respectively. This is still, 
however, a decrease for haema tob ium when compared to the 

1955 findings, which were 52% for this same area (note that 
Kafr El Sheikh was part of the Gharbiya governorate in 
1955) , and only slightly raised for These 

findings suggest that the prevalence of ^ 
changed only slightly, and ha em atobium has decreased 

since 1955. 

The most recent data collected in Egypt on prevalence 
and distribution of schistosomiasis was gathered in the 
Qalyubia governorate in 1976 by Alamy and Cline (1977). A 
systematic sample of every fourth household was selected 
from eight villages. Twenty-seven percent of the population 
was found to be infected with haema tobiu m and 40.5% with 
Sj ®99 counts of the respective specimens were 

made, which is frequently used as a measure of intensity of 
infection, e.g., the more eggs shed the more severe the 
disease. Relatively low intensity of infection was found 
for both species: a geometric mean output of 9 eggs/1Occ 
urine for Sj haemato biu m and 12.8 eggs/gram of feces for 
S« mansoni. 

In 1955, the prevalence of 3% and for 

Qalyubiya. The decrease in 
Sj haematobium prevalence of 4% is only a modest one and 
could be explained by a number of factors, including the 
typically focal nature of the distribution of the 
disease. The high prevalence of ^ mansoni. and 

correspondingly low egg count, are, however, very important 
observations. Looking back at Scott*s (1937) work (see 
Figure 4) , just to the north and east of where the Nile 
branches into the Rosetta and Damietta is the area of 
Qalyubiya, where S_. mans oni was also very low in 1935. This 
is the same area where the eight village sites selected by 
Alamy and Cline (1977) are located and where the prevalence 
1± MB§2£i ^3S now jumped from spotty isolated foci to a 
level indicating a major change, not only in prevalence, but 
also in distribution. 

Alamy and Cline (1977) have scrutinized their work in 
an effort to explain the changes observed in the prevalence 
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studies done by Alany and Cline (1977) in the early period 
of the study, it was shown that a much higher proportion of 
B, alexandrina to truncates snails could be found in the 
irrigation canals and drains of the studied sites. Quite 
the reverse was found in this same area by van der Schalie 
(1958). The current ratio of alexan drina to tr unca te 
found by Alamy and Cline (1977) was 24.5, whereas van der 
Schalie (1958) found a ratio of 0.104. This increase in 
ulexand rina snails, the primary host for mansoni, may 
account for the increase in the prevalence of S_. ma nso ni 
infection, b) A new technique for detecting man so ni ova 
was employed by the project. This technique, a modified 
formal-ether concentration procedure, has increased 
sensitivity of ova detection considerably over that which 
had been used in the past (Knight, et al^ 1976). Alamy and 
Cline (1977) suggest that this is a principal factor in 
finding an elevated prevalence. 

In conclusion, the prevalence of schistosomiasis in 
the Nile Delta has always been high, probably for almost a 
century, increasing at the time the delta was converted to 
perennial irrigation. mansoni has a more limited 

distribution in the north and central delta, whereas 
S. haematobium is found throughout. There is good evidence 
that Sj^ mansoni is invading new ground in the south central 
delta in Qalyubiya, (Alamy and Cline, 1977) where it had 
previously been at very low levels. There is also evidence 
that the overall prevalence of schistosomiasis in the delta 
is declining. This is best illustrated in the Beheira 
governorate, where data from three surveys taken over a 
period of 31 years is available fcr comparison and is shown 
in Table 10. The overall prevalence is shown for 1935, 
1955, and 1966 for h aematob ium. mansoni . and for 

either one or both infections (schistosomiasis). It 
declines continually for all cases from 1935. 


Schistosomiasis in Upper-Middle Egypt 


Frequently the environs south of Cairo, including the 
Giza plateau, are referred to as Upper Egypt. For purposes 
of presentation here, the area south of Cairo to Assyut will 
comprise Upper-Middle Egypt and will include the following 
governorates: Giza, Fayum, Beni Suef, Minya, and Assyut. 
Upper-Middle Egypt, as pointed out earlier, was, except for 
a few isolated areas, perennially irrigated by the 1930*s. 
The region south of Assyut to Aswan, where basin irrigation 
was still predominant in the 1930•s, constitutes Upper 
Egypt. The area south of Upper Egypt is called Nubia. 

Less historical data on schistosomiasis exists for 
Upper Egypt than for the delta. One of the most common 
features of Nile Delta surveys was that they were located 














Table 10 

Percent Prevalence of Schistosomiasis in the 
Northwestern Nile Delta by Selected Years 


T 

I 

b- 


Year 


Percent Prevalence 

-j- 


I 


haema tobium | mans oni 


Either 
One or Both 


H- 

1 


—-I— 

I 


1935(Scott) 1 

1 

53 

I 

j 

i 

I 

I 

54 

1955(EI1EH) 1 

1 

46 

31 

1 

1966(Farooq) | 

29.7 

28.5 


83 


40.9 


Prevalence of human schistosomiasis for the 
governorate of Beheira in 1935, 1955, and 1966. 
Prevalence data for infection with either one or 
both species of schistosomes for 1955 is not 
available. The data cited for 1966 have been 
corrected for the proportion found positive in three 
examinations on consecutive days. 


within easy reach of either Cairo or Alexandria. Distances 
considered short in the developed world render many sites 
inaccessible in the developing world because of poor and/or 
crowded road conditions and inadequate communication 
systems. Moreover, a number of important survey support 
facilities can only be found in the larger metropolitan 
areas. Attempting surveys south of Cairo in Opper-Middle 
Egypt has been and continues to be a formidable logistic and 
administrative challenge that increases with distance. 

In 1935, Azim surveyed a number of sites in Upper- 
Middle Egypt, as shown previously in Table 5. From each 
location, 200 persons were selected, presumably using an 
appropriate method, and examined for infection with 

haemat obiu m and Sj, manso ni. The findings were uniformly 
high for Sj. haematobium infection. Unfortunately, it is 
difficult to determine the location of these surveys simply 
from the name of the village. Up-to-date maps of Egypt are 
either restricted or non-existent. Not only are many of the 
villages named in this survey not present on available maps, 
but repetition of village names is common. 

Scott (1937) and the EMPH*s 1955 study are the only 
investigations attempting to survey the whole of Upper- 
Middle Egypt. The coverage of both surveys, although spread 
throughout, was spotty. Scott (1937) supplements this with 


























data collected from governmeiita 1 treatment centers which, as 
it turns out, agree rather well with his findings, although 
different sampling methods were employed. Only 

infection was found. As has been stated, 
S -2 found in the southern delta or south of 

Cairo. The prevalence of S_. haema tobium ranged from 41^ to 
90X, with an average of 60%. Figures 4 and 6 show the 
distribution of ^ haematob ium obtained from the random 
house-to-house survey and from the treatment centers for the 
area between Cairo and Assyut. 
the result of widespread use 
throughout the area, which had 
before Scott*s study (1937) . 


The notable uniformity is 
of perennial irrigation 
been established sometime 


Table 6 shows the results of the 1955 EMPH survey 
compared alongside Scott*s (1937) results. The overall 
prevalence declined from 52% in 1935 to 32% in 1955. A 
decline was also seen in each governorate. In Giza, both in 
1935 and 1955, sporadic cases of m anson i were found. 

Local health officials claimed that infection with 
m anso ni in Giza or in any governorate south of Giza can 
be assumed to have been acquired from the northern delta. 
This assumption is becoming increasingly risky to make, 
especially in light of the recent evidence from Qalyubia, 
where the distribution of S.mansoni is clearly changing. 
Other more localized surveys have been carried out in the 
Fayum, Giza, and in Assyut. 


In 1955, Zawahry selected a random sample of children 
from 0-12 years old, based on a 1954 social census frame in 
Shubramant, Giza (Zawahry, 1962). A sample of 762 children 
were selected, of which 691 gave specimens, 71 others moved 
or died, and 43 results were inadvertently lost. (It should 
be noted that such detailed accounting of the selected 
pcpulation is frequently overlooked when data are presented, 
and correspondingly the analytic value of the results is 
limited.) Helminthic and protozoan parasites were screened 
from the urine and stool specimens. Of the males, 25.9% 
were infected with hae m atob ium. No ^ man son i infections 
were found. 


In addition, Zawahry (1962) made an interesting 
observation. He found that the fcilharzial children had a 
greater likelihood of having a raultiparasitic infection. 
That is, the prevalence of infection with another parasite 
was higher in those children with hae mat obium infection 
than in children who did not have bilharziasis. It would be 
interesting if this relationship is true also for mansoni 
infection, and if other specific parasites were involved. 


Abdallah (1973), in 1970, surveyed 
Giza, Shanbari, and found 31.2% 
Sjs haemat obium. The survey was carried 
with a control project measuring the 

40 


a nearby area of 
infected with 
out in connection 
effectiveness of 














hycanthone as a chemotherapeutic* No mollusciciding was 
dene* A reduction to 2011 over a yearns time was achieved* 

The Fayoum is an area of 400,000 feddans and can be 
seen on the map in Figure 2 as a bleeb of the Nile to the 
west, south of Cairo* The water for this area is supplied 
through a single source canal (Bahr Youssef) which branches 
into almost 40,000 km of irrigation canals* In 1949, Khalil 
(1949) surveyed 2-6 year-old children in the Fayoum, of 
which he found 65*1% infected with haematobium. The 
number of those examined for each age, the number of 
positives, and the percentage positive are shown in Table 
11. A characteristic increase can be seen with the advance 
in age up tc 6 years* In 1968, 45% of the population of 
about 880,000 persons were infected with ^ hae matobi um* No 
S. manso ni infection has ever been detected in those who had 
never travelled outside the Fayoum- 


Table 11 

Age-Specific Prevalence of haematobiu m 

in the Fayoum, 1949. 

After Khalil (1949). 


■ 


II II 11 11 1 

1 II 1 

Age 

(Years) 

No. Examined 

Nc. Positive 

Percent 


2 

20 

5 

25 

3 

51 

26 

51 

4 

68 

38 

56 

5 

96 

65 

77. 6 

6 

112 

92 

82.1 

Totals 

347 

226 

65. 1 


Scott (1937) had found a somewhat higher prevalence in 
the Fayoum: between 67-84%. Since 1968, the Fayoum has been 
the site of a massive, and apparently successful, control 
project, carried out in cooperation with the EMH and the 
German Federal Republic. Prevalence has been steadily 
reduced to 8.1%, its present rate (Mobarkic, 1975). It was 
convenient that an effective application could be made at 
the Bahr Youssef Canal, just before it enters the Fayoum and 

















branches, thus avoiding a pieceneal application to the 
40,000 km of canals. Niridazole was used for mass treatment 
of the population witii emphasis on the school children. The 
health units and primary and secondary schools were employed 
for administration of treatment. This effort continues as 
an ongoing control program as of this writing. 

It will be interesting to follow the dynamics of 
ha ema tobium eradication. When prevalence is plotted 
against year, the curve seen in Figure 8 has a shape which 
suggests one of diminishing returns. In the Fayoum, 8.1% 
corresponds currently to about 89,000 persons in a 
population of 1.1 million, which is a sizeable reservoir of 
infection. 

In the Assyut area, four villages were surveyed in 
1968 by Hamman, et al. (1975). This study was the most 
recent of those concerned with demonstrating the 
relationship between irrigation systems and schistosomiasis 
transmission. Systematic samples were taken at the study 
sites, and urine specimens were examined by simple 
sedimentation. A prevalence of 34.5% was found in the three 
villages located in areas that were perennially irrigated. 
In a fourth village, where basin irrigation was still 
employed and, according to Hamman, et al. (1975) the only 
village of its kind remaining in the Assyut governorate at 
the time of the study, the prevalence was only 3%. (It is 
not clear what Hamman, ^ al. (1975) means by ”basin 

irrigation”. The flooding of the Nile River in Egypt had 
ceased altogether by 1964, when the coffer dam at the 
downstream diversion canal was dynamited and Lake Nasser 
began to fill. After 1964, the annual flood, necessary for 
basin irrigation, was trapped by the rising water of the new 
lake.) When this village is included with the other three 
villages, the combined prevalence is 25%. In the 1955 EMPH 
study, 16% of the sampled population of Assyut was positive 
for ha ematobiuro which is 36% less than Hamman, et ai.*s 
(1975) findings of 25%. However, the prevalence in the 
three villages with perennial irrigation schemes, i.e. 34.5% 
is probably more representative of Assyut as a whole and 
indicates an even greater increase. 

In 1955, three of the villages sampled by the EMPH 
study were still using basin irrigation and had 
correspondingly low prevalence, which, when added together 
with the findings from the villages using perennial 
irrigation, resulted in depressing the overall prevalence 
given for the area. Apparently, the selection of the 
village sites by the two studies reflected different 
research objectives. A more meaningful comparison might be 
one where prevalence only in the villages using perennial 
irrigation is used. The prevalence data for 1955 for only 
those villages in Assyut using perennial irrigation comes 
from a separate parallel study by the EMPH in which methods 







YEARS 


Figure 8. This graph was plotted after data obtained from the 
EMH (1975) for the Fayoum govemorate schistosomiasis control 
project. The first year of the control program was 1968. 


43 




of irrigation and the prevalence of schistosomiasis were, 
like Hamman, et al_;*s (1975) study, also being evaluated 
(Wright, 1973). The results of that study showed 68% out of 
19,043 persons examined were infected with haemai^^Uffi, 
or twice that found in 1968. 


Increased use of 
in increases in schis 
the Assyut governorate 
amount of land under 
perennial irrigation, 
increase in prevalence 
any given site under 
period may have been 
case, Hamman, et al 
perennial irrigation i 


perennial irrigation systems results 
tosomiasis prevalence in Assyut. In 
between 1955 and 1968 the limited 
basin irrigation was converted to 
It is possible that an overall 
followed, but that the prevalence at 
perennial irrigation over this time 
dropping. If this had not been the 
.•s results for the villages using 
n 1968 would have been higher. 


As part of the 1970 WHO-High Institute of Public 
Health study mentioned previously in the section on the Nile 
Delta, a sample population of 3229 persons was selected 
systematically from five villages near Beni Suef (Hussein, 
1S72). The study site is approximately 150 km south of 
Cairo in an area southeast of the Fayoura and has been under 
perennial irrigation from before 1935. The prevalence of 
SjL haematobiuB for all five villages was 24.1%. Thirteen 
persons were found to have MBSoni infections. Figure 9 
shows the age-sex prevalence distribution. 


Like the parallel study in Kafr El Sheikh, these 
results indicate that the prevalence of ^ haematobium is 
also declining in Beni Suef, especially when compared to 
Scott’s (1937) findings in the 1930’s of 82% (see Table 6). 
The 32% prevalence found by the EMPH 1955 study might be 
taken as an intermediate point in a long-term downward 
trend. 


in 


Sex related differences 
been recognized for 
significantly higher, 
is that the males are 
necessity of having 
agricultural fields, 
explanation for the difference, 
seen in the very early years, and 


prevalence have, of course, 
a long time, with males being 
The reason most often cited for this 
at higher risk due to the occupational 
increased water contact in the 
This is not an entirely satisfactory 

Barked differences can be 
in the adult age group the 


difference in prevalence between the sexes often is not as 
much (Farooq et al. ^ 1966; Hussein, 1972). In the Egypt-49 
project (Farooq,et al^ 1966) and in the Kafr El Sheikh study 
(Hussein, 1972) the differences in prevalence between the 
two sexes were less than six percentage points. However, in 
Beni Suef the prevalence in males was more than twice that 
of the females, 32.3% and 15.5%, respectively. A similar 
observation was made by Hamman, et al^^ (1975) in Assyut. 
Differences in prevalence in male and female by region 
cannot be analyzed from data collected by Scott (1937) or 

44 





% PREVALENCE 



AGE (YEARS) 


Figure 9. The age-sex specific prevalence of S. haematobium in 
selected sites of the Beni Suef govemorate in 1972. After 
Hussein (1972). 


45 






the 1955 EMPH study (Wright^ 1973). Both studies coiabiaed 
their findings from different regions of Egypt when 
presenting sex-specific data. This is unfortunate, for it 
would be interesting to see if a sex-related differential 
was developing over time. 

There is an obvious need here for sex-specific data to 
be collected and presented in a manner that would facilitate 
comparison by region^ There are no answers or even 
implications of what changes in sex-specific prevalence 
might mean (perhaps an indication of the impact of health 
education), but this is no reason to ignore them, especially 
when this is simply a matter of research design rather than 
additional field work. 

In brief, the surveys carried out in the area of 
Upper-Middle Egypt are in general agreement with each other. 
S.. mansoni was not present or, if so, could be explained by 
showing that the infected persons had spent time in the 
delta or had originated from there. hae mato bium was 
found uniformly throughout the area at a prevalence similar 
to that of the delta and reflected the widespread conversion 
of land from basin irrigation to perennial irrigation. In 
fact, haem atobiu m infection had been abundant from at 
least the middle of the 1930*s. In the future, the Fayoum 
must be considered separately as an area of Upper-Middle 
Egypt where schistosomiasis is rapidly coming under control. 


Schistosomiasis in Upper Egypt 


The area of the Nile between Assyut and the old Aswan 
Dam is termed Upper Egypt. yhen Scott (1937) surveyed this 
area in 1937, basin irrigation was practiced throughout the 
district except in the Kom Ombo plain. Large sugar 
plantations were developed in Kom Ombo during the 1930*s, 
requiring the conversion of land to perennial irrigation. 
The Kom Ombo plain is similar to the Fayoum aneurysm, except 
that it is smaller in area and bulges to the east, not the 
west. The Kom Ombo plain is not as “pinched off” from the 
Nile as the Fayoum and is watered by numerous different 
canals rather than a single canal as in the Fayoum. Figure 
10 is a LANDSAT photograph of Kom Ombo, Aswan, the AHD, and 
a northern portion of Lake Nasser. 

Khalil and A 2 im»s (1935) research into the causal role 
of perennial irrigation schemes, pumps, and canals in the 
“introduction of infection with haematobium” was carried 
out in Kom Ombo in the early 1930’s. Khalil and Azim (1935) 
surveyed villages before and after conversion to perennial 
irrigation and found that prevalence reached levels similar 
to that of the delta in as little as three years following 

conversion. These results are shown in Table 1. 

46 







Figure 10. This is a photographic reproduction made by a LANDSAT 
satellite of Upper-Middle and Upper Egypt. Included in the lower 
portion is Lake Nasser. Just north of Lake Nasser is Aswan and the 
Korn Ombo plain. 


47 



Scott (1937) found in 1937, however, that the areas 
north and south of Kom Ombo had a very low prevalence of 
haemat ob iuB* Again, no Sj, mansoni was seen. The previous 
Figures 4 and 6 show this distribution, which included the 
results taken from governmental data. Generally, the 
prevalence of haematobium was 5^ or less in Upper Egypt. 


Data from the EWPH 1955 survey as shown in Table 6 
reveal some of the most dramatic increases in prevalence so 
far seen. In two of the three governorates of this region, 
Sohaq and Aswan, the prevalence increased considerably, 
while in Qena it remained unchanged. The increase from 3% 
to ^^% in Sohag reflects the conversion of the governorate 
to perennial irrigation previous to the 1955 study. Large 
proportions of the Aswan governorate were also converted to 
perennial irrigation, which already included the Kom Ombo 
agricultural plain, correspondingly, the prevalence 
increased from 13% to 23%. The increase probably would have 
been greater had the remaining portions of the governorate 
still using basin irrigation (the northern part of the 
governorate and south of the Kom Ombo plain) been converted. 


Between 1955 and the 1960 
which was predominantly basin ir 
areas of the Aswan governorate an 
converted to perennial irrigatio 
these areas since then is proba 
but little current information 
unpublished WHO report by Dazo a 
unpublished, the report has been 
quoted as evidence of the impact 
of schistosomiasis prevalence (van 




the Qena governorate, 
rigated, and the remaining 
der basin irrigation, were 
n. What has happened in 
bly what everyone expects, 
exists except for an 
nd Biles (1972). Although 
widely circulated and even 
of the AHD on the increase 
der Schalie, 1972). 


In this influential study, sites 
Assyut, Idfu (50 km north of Kom 


were 


Kom Ombo, and in 
from urban areas 
area of Assyut, 


resettlement sites of 
sites were selected 
governorate. In the 
found in 30% of those 
an overall prevalence of 75% from 
obtained. From the three villages 
prevalence of 32,4% was found, and 
prevalence of 19% was observed, 
summarized in Table 12. 


selected in 
Ombo), the Nubian 
the Aswan area. No 
or from the Qena 
haematobium was 
examined from two villages. In Idfu, 

three villages was 
surveyed in Aswan, a 
for Nubia a combined 
These results are 


Certain 
the level of 
expected sin 
conversion to 
when Dazo and 
are, however, 
results epide 
from a brief 
selection did 


ly these findings show 
prevalence seen in the 
ce there had been 
perennial schemes f 
Biles (1972) carried 
certain aspects of th 
miologically unsound, 
examination of the 
not provide a represe 

48 


an increase compared to 
1930*s. An increase was 
ample time since the 
or prevalence to increase 
out their survey. There 
is survey that render the 
First, it is obvious 
data that the method of 
ntative sample population 





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49 









fcr age or for sex. The younger age groups were greatly 
over-represented in the sample, and, as pointed out earlier, 
in Upper Egypt, especially in Aswan, adult females far 
outnumber the adult males in the general population. There 
was not a single village surveyed by Dazo and Biles (1972) 
where more women were selected than men. That could 
possibly have been corrected by appropriately weighting the 
selected population for age and sex. This, unfortunately, 
was not done. The major difficulty, however, is one of non¬ 
response and self-selection. If 100 persons are selected, 
using an appropriate method, and results are obtained for 
only fifty, the non-response rate is 50%, or the number not 
giving results/total selected X 100. To give only a typical 
example, in the village of Mankabael near Assyut, there are 
13,000 inhabitants. Ail those between 2 and 25 years old 
were requested to give a urine specimen. A total of 123 
responded and gave specimens. Eased on their method of 
selection this is over a 99% non-response rate. It cannot 
be presumed that the non-respondents are typical of and 
similar to the respondents. 


It would be very worthwhile to have recent 
quantitative data for Upper Egypt. However, the results 
from Dazo and Biles (1972) and of Tuli (1966), who completed 
a limited survey in Aswan, only indicate that 
is present. The exact proportion of the population infected 
cannot be determined with any certainty from these reports. 


In brief, very little recent or accurate data is 
available for Upper Egypt. The prevalence of haematobium 
was low in the area prior to the use of perennial 
irrigation, but the entire area has since been converted to 
perennial irrigation. It is expected that hae m ato bium 
infections would greatly increase following the conversion 
tc perennial irrigation systems, and data provided by Dazo 
and Biles (1972) and also by Tuli (1966) indicate that it 
has. The exact figure of increase and when it occurred 
remains, however, unknown. 


Schistosomiasis in Nubia 


Egyptian Nubi 
Valley between the 
now inundated by La 
is quite distinct 
having different 
separate tribes, th 
Eadiga, comprised a 
in New Nubia in 196 
began to flood the 
been constructed al 
agricultural plain 


a was formerly the area along the Nile 
old Aswan Dam and the Sudanese border. 

The population from this area 
general Egyptian population, 
dress and language. Three 
the Arabs, and the Hahas or 
bout 50,000 persons. All were resettled 
4 when the rising waters of Lake Nasser 
ir original home sites. New Nubia has 
eng the eastern periphery of the Kom Ombo 

. The villages retain their original 

50 


ke Nasser. 

from the 
styles of 
e Kenuz, 






names and geographical distribution^ with the Kenuz in the 
north, the Arabs in the middle, and the Mahas or Fadiga in 
the south. Often neighbors were settled with neighbors. 
But a population living along 400 km of river bank is now 
compressed into an area approximately 50 km long bordered on 
one side by a canal. Figure 11 shows this resettlement 
pattern. 

Dawood (1951) recognized that bilharziasis, 
transmitted by snail vectors, was present in Nubia but did 
not provide data on distribution or prevalence of the 
infection. Rifaat and Nagaty (1958) surveyed the Nubians 
for a number of health parameters, including 
schistosomiasis. Seven villages were surveyed, and some 553 
urines were examined. Table 13 shows these results. Table 

13 also shows to which tribe the village belongs and whether 
or not perennial irrigation schemes were present. It is 
interesting to note that perennial irrigation schemes were 
being installed at this early date in Nubia. Also shown in 
Table 13 arc the number examined at each village, the number 
positive for Schistosoma ova in the urine, and the percent 
positive. An overall prevalence of 40% was obtained. Table 

14 shows the age-specific prevalence rate with the younger 
members having a typically higher prevalence. Table 14 also 
shows the number of each age and sex who were examined. It 
is quite evident that the females, especially in the older 
age groups, were under-represented. Rifaat and Nagaty*s 
(1958) survey suffers from the same defects that were found 
in the study by Dazo and Biles (1972). Not only is the 
population incorrectly represented, but the method of 
selection is not discussed , making it impossible to know 
the probability of being selected. It is known that 1369 
persons were, by some unknown method, selected and that 553 
gave urine specimens, which is a 40% non-response for 
specimens alone. Accordingly, these results cannot be taken 
as accurate estimations of the prevalence of schistosomiasis 
in the Nubian population at that time. 

It is very fortunate that a survey just previous to 
the resettlement of the Nubians was carried out in 1964 by 
Zawahry (1964) in which the shortcomings of the previous 
surveys, and those of many of the surveys of Egypt, were 
avoided. A multi-stage stratified random sample based on 
the 1960 population census representing each of the three 
tribes was the frame for sample selection. Every individual 
in the Nubian population had a chance of being selected. 
This chance was calculated as a probability, which is the 
basis of any sound statistical analysis of survey data. 
From these prevalence figures estimates can be made with 
given degrees of confidence. 

An overall estimate of 15.2% of the Nubians had 
h^matgbiuff, less than half that found by Rifaat and 
Nagaty^ {1958f. Because of differences in methodology. 





Figure 11. This is a map of the Korn Ombo area showing the resettle¬ 
ment pattern of the Nubian tribes. 


52 


































Table 13 


The Percent Prevalence of S_. haegatobiuia^ 1958. 
After Rifaat and Nagaty, (1970)♦ 



* 

1 M ■ 


■ 

Village, Type 
Irrigation, and 

of 

Tribe 

No. Persons 
Examined 

No. Positive 

S . haematobium 

Percent 

El Dakkah 
Perennial 

Kanooze Tribe 

132 

47 

36 

Kurta 

Basin 

Kanooze Tribe 

83 

12 

1 4 

El Malki 
Basin 

Arab Tribe 


104 

67 

63 

Einefca 

Both 

Fadiga 


87 

11 

12 

Ballana 

Perennial 

Fadiga 


82 

56 

68 

Arminna 

Basin 

Kanooze 


32 

12 

37 

Total 


520 

205 

39 


♦Caution should be taken when interpreting these 
findings. There is no evidence to show that the 
population selected was representative. 

especially saapling protocols, it is quite impossible to 
compare the two surveys. However, the work of Zawahry 
(1964) lends itself easily to future studies or follow-up 
studies for purposes of comparison. Naturally, comparative 
studies require that laboratory and other data gathering 
methodology be consistent. This is only possible if details 
of the aethcdolcgy employed are described as was the case in 
the report by Zawahry (1964). 

All too frequently, reliable baseline data do not 
exist for populations in Africa and in other developing 
















Table 14 


Age-Specific Prevalence of Jl§§i 5 ^jtobiurar Nubia, 1958. 
After M-A. Rifaat and H. F. Nagaty, (1970). 


Age 

(years) 

% Positive for 

S. haematobium 


o 

1 

—— 


5-9 

56.0 


10-14 

30.0 

Total Sample=1,387 

15-19 

43.0 

Males=1,083 

20-29 

14.0 

Females=304 

30 + 

18.0 


ALL AGES 

40.0 



areas where large man-made lakes have been built. 
Demonstraticns of changes in health patterns arising from 
lake-making are difficult, if not impossible, when data are 
lacking prior to dam construction. Typically, impact 
statements on the effects on health of these water 
management schemes rely only on data collected following 
construction of dams. Zawahry’s (1964) work makes it 
possible to assess accurately the Nubian population now that 
they have teen resettled. Trends can be estimated, and the 
impact of the environmental changes resulting from 
displacement can be made. 

Details of Zawahry*s results have been reproduced in 
Tables 15, 16, and 17. Table 15 shows the age and sex of 
persons who gave urine or stool specimens by village and 
tribe. The total sample of 925 individuals, close ly 
reflecting the demographic composition of the 1960 Nubian 
population were selected. Table 16 shows the age-sex 
specific prevalence for the sample. Typically higher levels 
of prevalence are seen in the younger groups. The prevalence 
by village, hamlet, and sex can be seen in Table 17. The 
dramatic difference in prevalence between Kurta and the 
other two villages reflects differences in irrigation 
practices. Snail surveys carried out by this study were 
unable to find vector snails along the Nile banks, although 
a total of some 44 km were surveyed and 1320 dips were made. 
Snails were found in 1 % of the 600 dips made in canals where 
perennial irrigation projects had been established. 

54 

















Taole 15 

Distribution ot individuals Who Submitted Urine and/or Stool Sped 
by kqe. Sex, and Locality (Tribe) > ^^lbia^ Egypt^ U.A.R*, 1963 

After Zawahry (1964). 


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As mentioned, Dazo and Biles (1972) surveyed a sample 
of Nubian resettlement villages in 1972 in the Kom Ombo 
agricultural plain* If their estimate of 1951 prevalence, 
which is not a great deal different from the 15.2% found by 
Zawahry, is true, then little change in schistosomiasis 
prevalence has resulted from relocation. These two surveys, 
however, lack comparable features in their methodology. 
Thus, any conclusions drawn must be taken with the utmost 
skepticism. Certainly no uneguivocal epidemiological 
statements can be made. 

It can be concluded that recent accurate estimates of 
Si haem atob ium^ the only species present, in Old Nubia have 
been made, and the provisions of the methodology have been 
met providing grounds on which reliable assessments can be 
made in the future. 


Schistosomiasis in Lake Nasser 


In 1964, the coffer dam at the head of the diversion 
canal, just scuth of the new AHD, was dynamited. Hater 
began to fill in behind the then yet uncompleted AHD. By 
1970, the AHD was completed, and by 1975 Lake Nasser had, 
predictions outstanding, filled. All of Old Nubia was 
flooded, which included agricultural lands and a number of 
pharaonic sites. 

HHO sent four missions to lake Nasser in the period 
between 1970 and 1974. Satti (1970) estimated that there 
were 3307 fishermen working along the shores of the lake and 
examined about 14%, or 463 persons, for urinary 

schistosomiasis. Twenty-nine percent had infections, and 45% 
of a smaller group of fishermen examined at the Aswan 
Hospital had infections. Dazo and Biles (1971) surveyed 
fishermen along the entire length of the lake and found that 
51% of 111 were infected. The only permanent population on 
the shore of Lake Nasser is at the Abu Simbel temple. The 
134 persons there cannot be considered local indigenous 
inhabitants, but are rather Government employees coming from 
a variety of locations from all over Egypt. Nine percent 

hae matobiu m infections. The remaining shoreline of 
the lake was ”a vista of barren rock and arid sand” (Dazo 
and Biles, 1971). In 1972, 23 out of 32 fishermen (72%) 

were demonstrated to have hae ma tobi u m infections (Dazo 

and Biles, 1972). In 1974, Scott and Chu (1974), 
consultants for HHO, reviewed these findings and concluded 
that it was impossible to tell if infection was being 
acquired from the lake or from endemic areas of Upper Egypt 
during periods when fishermen were visiting their families. 
Each investigation included a malacological survey. Between 
1970 and 1974, snails of the species Bulinu s truncatus, the 
vector host for ^ h ae m ato bium^ were found throughout the 

56 ~ 

















ent Prevalence of Eilharziasis by Age and Sex; 



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lake in the south as well as 
and western shores. A large 
No infected snails were found 
of the lake. 


the north and on both eastern 
number of foci were observed, 
except near the High Dam area 


In briefs Lake Nasser is populated by 3,000-5^000 
transient fishermen and there are no permanent settlements 
located along the shore of the lake, except at Abu Simbel 
where there is a small group of government personnel 
stationed for maintenance and care of the temples (Dazo and 
Biles, 1971), There are vector snails present throughout 
the lake. There is an indication that a large number of the 
fishermen are infected with ^ Transmission in 
the lake may be limited to the area near the AHD. 


Schistosomiasis in the Desert and Reclamation Sectors 


The remaining settlements in Egypt are located along 
the western Mediterranean shore and at desert oases. In 
1952, the population of the Dakhla Oasis had a 
schistosomiasis prevalence of 65% (Abdallah, 1973). 
Repeated mollusciciding had reduced this prevalence to 0.7% 
by 1957 (Nagaty and Rifaat, 1957). Rifaat et al. , (1963) 
confirmed these again in 1963. Rifaat, et al_j^ (1964) 
surveyed Wadi El Natrun, also a desert site, in 1964 and 
found only those that had recently come from the Nile Delta 
had schistosomiasis infections. Also in 1964, Rifaat (1964) 
looked at the western coast at Merso-Matruh and again found 
the area free of schistosomiasis. 

Those areas of Egypt not watered by the Nile, i.e., 
the western coastal region and desert area, are apparently 
free of schistosomal infections either because of control 
programs ox because of the lack of perennial irrigation 
schemes. 

New reclaimed lands comprise important new areas into 
which the schistosome species have a high likelihood of 
being introduced because of the associated irrigation 
expansion. The area between Cairo and Assyut is an example 
of land reclamation that took place over 40 years ago. 
Reclamation in this discussion, however, will be reserved 
for those areas in which there was no previous indigenous 
population and, thus, must be settled with persons 
originating from elsewhere. An example of such an area is 
cited in the previously mentioned Egypt-49 project in the 
Beheira Province. Moreover, because of the new additional 
water resource, some 1X10^ feddans have been proposed for 
reclamation. It is interesting to note that while new lands 
have been reclaimed in the last 15 years, there has been a 
net loss of cultivated land in Egypt due primarily to urban 
sprawl, military construction, and road construction 




(Haterbury^ 1974)• Also, after the outbreak of hostilities 
in 1967, reclamation activities were delayed* 

Schistosomiasis in Egypt; A Summary 


In Egypt, schistosomiasis, also known as bilharziasis, 
is caused by infection with either S_. haematobium or 
ma ns oni, or both* Snails of the species Bulinus 
and Bio mpha laria ale xandrina are the respective 
vector hosts* Schistosomiasis in Egypt has been present 

since pharoaic times. In the latter part of the last 
century and in the early part of this century, the Nile 
Delta was converted from basin irrigation to perennial 
irrigation, which brought with it widespread infection with 
both species of schistosomes and rendered the delta 
”hyperendemic”. Recent studies in the delta show that 
schistosomiasis is still quite prevalent, although not as 
high as it had been earlier. Numerous control projects have 
been carried out, and it should be noted that 
mcllusciciding, chemotherapy, environmental and educational 
programs have been, and continue to be, ongoing activities 
at the some 2140 rural health units and centers, in the 
secondary schools, and at the 162 endemic disease treatment 
centers. The relationship between perennial irrigation and 
schistosomiasis transmission has been repeatedly 
demonstrated. In addition, gansoni infection was found 

to have a limited geographical distribution restricted to 
the delta. Sporadic cases have been seen in Giza and in 
Beni Suef. 


Before 19 40, prevalence of hae ma tobium was found to 
be high (601 cr more) in the area south of Cairo and north 
of Assyut where perennial irrigation has been the 
predominant method of cultivation. This includes the Fayoum 
area. Recently, control programs have considerably reduced 
the prevalence of S^ haematobiuja in this area. The data 
from 1955 strongly suggest that an overall drop in 
prevalence was occurring when compared to the 1937 studies. 


From Assyut south to Aswan, only ^ ha emat obium is 
found, and before 1940 hae mat cbium prevalence was very 
low, except in the Korn Ombo plain (Scott, 1937). Surveys 
carried out between Aswan and Assyut in 1972 (Dazo and 
Biles, 1972) inconclusively suggest that there has been an 
increase in S^ h aematobiu m prevalence since the area has now 
been completely converted to perennial irrigation. Basin 
irrigation was no longer found after 1965 in Egypt (Dazo and 
Biles, 1972). Excellent historical data exists on the 
prevalence of schistosomiasis in the Nubian populations 
before resettlement in the Kom Ombo plain but no conclusive 
studies have been completed to assess changes following the 
Nubian resettlement. Clearly, these two areas are prime 

60 













sites for assessing changing patterns of 
infections. This does not mean that studies 
carried out on the fishermen populations in L 


at reclamation sites, 
organized to follow 
Nasser by the EMH as 
regional project (IH 
Lake Volta, Ghana. 


Indeed, surveys are c 
schistosomiasis transmi 
a companion study to 
9658RAF/71/217) on schi 


schis 
should 
ake Nas 
urrentl 
ssion 
the MHO 
stosomi 


to 

som 

ai 

n 

ot 

be 

se 

r. 

or 

y 

bei 

ng 

in 

La 

ke 

• 

1 

nte 

r- 

as 

is 

in 


Ir rigation Expan sion and the Aswan Hig h Dam 

Since irrigation schemes are a critical factor in 
transmission and spread of schistosomiasis in Egypt and 
because irrigation schemes were to be expanded as the AHD 
complex was completed, it is important that all available 
information concerning the development and implementation of 
irrigation projects in Egypt be included as a part of this 
review. 


To reiterate, both the reclamation of new lands (lands 
uncultivatable previous to the AHD because of limited water 
resources) and the conversion of basin irrigated land to 
perennially irrigated land were cited as projects which 
would result in the increase of schistosomiasis in the 
population. The areas of interest for reclamation have been 
in the eastern desert regions between the Nile Delta and the 
Suez Canal and west of the Nile Delta, south of Alexandria, 
where reclamation has been very active in the recent 
past. Since the 1930*s virtually all land under basin 
irrigation has been located in Upper Egypt, and it is in 
this area that schemes for conversion to perennial 
irrigation have been focused. 


The term ’’perennial irrigation” has been rather 
loosely applied, usually indicating simply the improvement 
over basin irrigation by installing pumps to raise water for 
cultivation rather than wait nine months for the next flood. 
In effect, basin irrigation in Upper Egypt was frequently 
being ’supplemented” during the months without flood 
waters. A good example of this type of ’’perennial 
irrigation” was described by Khalil and Azim (1938) in their 
original work on the impact of irrigation schemes and the 
transmission of schistosomiasis in Upper Egypt. Another 
example was in old Nubia where pumps and canals had been 
installed at selected sites as pointed out earlier (Zawahry, 
1964), and where schistosomiasis had increased. In villages 
where standard basin irrigation was continued, without pumps 
and canals, prevalence was low. 


The type of pump used for these earlier ’’perennial” 
schemes was characteristically a large gasoline-driven pump 
housed on a floating platform (see Figure 12). These 






••floating pump houses^*, which are still commonly seen docked 
along the river banks of Upper Egypt^ were designed to 
provide water to canals regardless of wide variations in the 
water level or discharge of the Nile typical of the era 
before construction of the AHD. Many of these pumps still 
function^ but government-funded irrigation expansion has 
installed more modern electrically driven concrete-housed 
pumping complexes capable of lifting much greater volumes of 
water, thus increasing the potential for year-round 
cultivation. Irrigation engineers typically refer to these 
schemes as perennial or ••permanent** irrigation, and 
irrigation practices previously used were vaguely described 
as basin irrigation. In a sense this is correct because 
land was flooded in Upper Egypt before the coffer dam was 
cleared in 1964 and the lake began to fill. Nevertheless, 
the floating pumps and their related canals and drains were 
also present. This has resulted in a degree of confusion as 
to what has been irrigated and how in Upper Egypt. The 
number of floating pumps, when they were installed, and the 
amount of land serviced is not known, as productive sources 
of information on the development of irrigation schemes of 
any kind are scarce. The data obtained from Egyptian 
governmental sources (EG, 1977) and translated from Arabic 
(see Tables 18 and 19) provide a limited amount of insight 
on the number of feddans converted to "permanent** irrigation 
in Upper Egypt, According to the data reproduced in Table 
18, Aswan was completely converted to ••permanent** irrigation 
daring the period between 1933 and the present, and, by 
1974, there were 92 thousand feddans yet to be irrigated by 
••permanent** methods in all of Upper-Middle and Upper Egypt. 
Table 19 is a more detailed break-down, by year, of when 
irrigation conversion by the governmental agencies was 
carried out. For example the 282 thousand feddans available 
for conversion in Qena governorate were irrigated by 1969. 
There was no change in the number of feddans converted in 
the Sohag governorate from 1965 to 1974, indicating that the 
irrigation projects were completed by 1965, except for 34 
thousand feddans still to be converted. A total of 881 
thousand feddans of Upper-Middle Egypt and Upper Egypt were 
converted to **p€rmanent** irrigation in the 15 year period 
between 1959 and 1974, according to these government 
figures. 

Note in Table 17 that the region proposed to be 
irrigated in 1959 in Sohag comprised 295 thousand feddans, 
virtually the entire area of this governorate. According to 
the inforiatioc in Table 17, the government engineers 
apparently considered Sohag as an area under basin 
irrigation in 1959. However, the results of the 1955 
schistosomiasis survey (EMPH, 1955) showed sharp increases 
in schistosomiasis prevalence indicating that at least some 
man-made irrigation schemes were already present. This 
increase occurred before the implementation of the large 
••permanent** government funded irrigation projects. 

62 


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Figure 12. A "floating pump station" in Qena. 


64 


i:/ -v*- 










Table 19 

Conversion to ”Perffianeiit” Irrigation by Year 

in Selected Governorates 




After 

Shindy 

(1977) 



Year 

Cumulative 

Number of 

Governorate 
Feddans Converted 

(in Thousands) 

Qena 

Schag 

Assyut 

Minya 

Beni Suef 

Before 

1965 

282 

295 

266 

86 

44 

1965 

38 

261 

239 

0 

0 

1966 

50 

261 

239 

0 

0 

1967 

201 

261 

239 

0 

0 

1968 

282 

261 

239 

0 

0 

1969 

282 

261 

256 

11 

0 

1970 

282 

261 

266 

44 

0 

1971 

282 

261 

266 

61 

0 

1972 

282 

261 

266 

64 

1 

1973 

282 

261 

26 6 

69 

1 

1974 

282 

261 

266 

71 

1 


Obviously^ {:uiBps, mcst likely the kind shown in Figure 12, 
and canals had been installed in many areas of Sohag during 
the late 1940*s and early 1950*s, but there are no data to 
confirm this. The question is^ ”Did Qena, after 1955, when 
schistosomiasis prevalence was still low (EMPH, 1955), 
expand irrigation systems, using the ’floating pump* 
system?” It is probable that, like the other areas of Upper 
Egypt, Qena’s first irrigation expansion occurred before the 
ARD complex was begun. The ”floatinq pump” structures can 
still be seen docked along the Nile banks of the Qena 
governorate, indicating that at some point in time these 
pumps were used for irrigation. Therefore, the possibility 
should be considered that schistosomiasis prevalence had 
increased or was increasing in the governorates of Upper 
Egypt, as a result of these earlier irrigation methods, 
before the iaplenentation of the larger government 
irrigation schemes, and before the AHD was begun. 

65 

















Waterbary (1974) has pooled information on land and 
water use in Egypt in an excellent review article. Table 20 
from Waterbary’s (1974) article shows the cropped area by 
season and year. Note the drop in number of feddans cropped 
in the autumn between 1952 and 1966. It was during this 
season that the Nile flooded. After 1964, cultivation could 
be increased during the productive summer months. Figure 13 
graphically shows the interesting relationship between the 
growth of the population and agricultural expansion. 


According to Waterbary (1974), more land was reclaimed 
before the AHD than after it. By 1973^ 902,000 feddans had 
been reclaimed, of which about half were being cultivated. 
Flany of the areas selected for reclamation were of marginal 
quality requiring great expenditure before cultivation was 

agricultural area seems to be 
increasing. Although 902,000 new 
there was a net loss of 200,000 
feddans by 1973 due to urban expansion, road building, 
factories and military installations. 


possible. Indeed, the 
decreasing rather than 
feddans had been added. 


Aside from the fact that land reclamation seems to be 
rather limited at this time, there is doubt that reclamation 
as such is a mechanism for causing an increase of 
schistosomiasis in Egypt. To illustrate this point, 
envisage an area, devoid of farms and settlements. With the 
increase in available water, the area is irrigated and 
developed into state farms. Families, most likely non¬ 
landowners, are brought in and settled. These resettled 
families and their members are now at risk of acquiring 
schistosomiasis, but were they not already at risk? Are not 
many of them already infected, having long since acquired 
the infection at village homes in the delta or in the south? 
It is doubtful that many of the families that move to 
reclaimed lands originate from urban settings. Thus, land 
reclamation imposes a risk of changing the geographic 
distribution of the disease, but is unlikely to cause an 
increase in the prevalence of schistosomiasis in the 
population. Changes in the distribution of schistosomiasis 
certainly complicates control, but increases in prevalence 
in the population have far greater implications. 


Environmen tal He alth Conditions in Egypt 


The historical information sought for environmental 
health conditions in Egypt included the following: 

1) General village sanitation 


2) Rural 

3) Rural 


water supply wastewater practices 

wastewater practices 

66 








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67 













INCREASE OF POPULATION 



Figure 13. The relationship between population growth and agricultural 
expansion. The lines representing cultivated and cropped areas for 
1970 are overestimates. After Waterbury (1974). 


68 










4) Rural housing ccaditions 

5) Refuse or solid waste practices* 


Detailed analytical information on these parameters is 
rather limited for Egypt as a whole* Several local studies 
are available however for the delta and for Old Nubia, Data 
from these studies have been provided in somewhat greater 
detail* 

Amin and Zaghloul (1959) in 1959 reviewed the 
administrative organization of the EMH environmental 
services but provided little data. They did point out that 
by 1959 protected rural water supply had been provided to 
each village over 1^200 persons. Generally, water was 
pumped from an underground source to elevated tanks which 
supplied a limited number of public water standpipes (one or 
more taps fixed to a vertical concrete slab). This water 
supply project had been started in the 1940*s and by 1960 
fairly wide coverage was obtained. In 1975 all villages had 
at least one protected source of water. The goal of one 
standpipe per 300 persons was 90-'95% completed by this time 
(furnia, 1975). This is very impressive when compared with 
the water supplies available in the rural villages of other 
similar developing countries. Installation of latrines in 
the rural areas has been less successful (Furnia, 1975), 

The major refuse problem in Egyptian villages is 
animal waste (Headlee, 1933; ieir, et al . (1952), Animal 
manure is still commonly used for composting and for cooking 
fuel. The compost heaps and the drying dung cakes cause a 
serious sanitation problem by providing ample sites for fly 
breeding. For the most part, solid waste in the 
conventional western sense does not exist in Egyptian rural 
villages. Only infrequent isolated litter piles may be 
noted in typical villages. However, where multistoried 
housing projects have been constructed and in urban areas 
there are extensive solid waste problems. On the village 
level very little solid non-organic material is discarded. 
This picture is now beginning to slowly change as the 
population grows and as more consumer goods become available 
to the rural populations. 

Focusing on the delta, Headlee (1933), made detailed 
environmental observations on the rural village of Rushdy, 
Qalyubia. No clinical data were provided but excellent maps 
were made showing the defecation sites in the village. 
Samples were taken from these sites and examined for 
helminthic parasites, Enter obius. A scaris . Trichuris, 
Hymenoiepis, and Ancylostoma were detected in the samples, 
Defecation"habits did not center around any favored site in 
the village area but were scattered throughout. This habit 

of ”indiscriminate” defecation at many different locations, 

69 






locations which often provided little or no shelter, rather 
than at isolated places (for example, palm stands) was also 
observed by Scott {1937)* 

According to Scott (1937), this indiscriminate habit 
has important implications concerning hookworm transmission. 
If the same defecation sites were frequented then hookworm 
transmission would be favored. However, defecation sites 
were scattered and, as Scott (1937) showed, the prevalence 
of hookworm was not as high as might be expected. 

Headlee (1933) also observed the still common practice 
of disposing household wastewater in the village streets and 
that the presence of a stable attached to the home 
contributed to the intense fly problem. Farooq, et 
(1^66a) commented that village conditions “in the delta 
had changed little since Headlee*s report. 

Weir, et al*.*s (1952) study (1952) of the same general 
area (Sindbis, Qalyubia) confirmed Headlee*s observations. 
\ie±r et al_. (1952) also found that 31% of all the homes in 
the study area had latrines out of a total of 4,878 houses 
examined, and 10% had wells. Flies in the study site were 
noted in large numbers. Counts were made monthly on the fly 
populations. These counts showed seasonal fluctuations with 
low numbers in the middle winter months and high counts for 
the remainder of the year. Measures were taken to reduce 
the fly populations, and it is interesting to note that 
during a two year period in the areas where control was 
maintained, infant mortality was markedly reduced. This is 
a very important observation. No other environmental 
measure tested during this study demonstrated any 
improvement in infant mortality, indicating the overwhelming 
importance of flies as vectors of serious infantile 
diseases. 

In 1966, Farooq, et al^ (1966a), found that 87.6% of 
the people in Beheria, in the north western delta, had piped 
water, a 11% increase in the number with piped water since 
1952. The exact distribution of people with or without 
piped water is shown in Table 21. Ten and a half percent of 
the sample used canal water exclusively. 


Table 22, reproduced from Farooq's study, shows the 
number and distribution of people by type of house. There 
were considerable differences between divisions with an 
overall 50.5% living in stone or redbrick houses and 40.3% 
living in mud or mud brick houses. Farooq, et al . (1966) 
also determined the number of persons with a cowshed and the 
number and distribution of latrines. They found that just 
over half of the population do not have cowsheds, 32.9% have 
adjoining cowsheds, and 14.4% have separated cowsheds. The 
latter group were considered to be in a higher economic 
class than the former two. At these study sites 52% of the 

70 







Table 21 

Distribution of Exacained 
Population by Source of Hater Supply, 
After Farooq, ^ aK (1966). 


Hater 

Supply 

Number 
of People 

Percentage 

Distribution 

Canal 

1248 

10.5 

Piped Hater 

10466 

87.6 

Other 

70 

0.6 

Not stated 

160 

1.3 

Total 

11944 

I 

o 

o 

• 

o 


population was found to have latrines; 10SI had latrines and 
did not use thea* (It would be interesting to know just how 
this was determined,) 36.4% did not have a latrine. This 
indicates that there is an increase in the number of 
latrines in the homes since Heir^ et al^*s (1952) time. 


Table 22 

Distribution of Examined Population 
by Type of Housing. 

After Faroog et al^, (1966a) 


Type of 

House 

Number 
of People 

Percentage 

Distribution 

Stone or Red Brick 

6988 

58. 5 

Mud brick or mud 

4811 

40. 3 

Other 

7 

o 

• 

o 

Not Stated 

138 

1.5 

Total 

11944 

100.0 


71 

































As shown in the previous sections on schistosomiasis 
all the above environmental parameters influenced the 
transmission of infection, with the exception of latrines 
which showed a marginal decrease in prevalence, and only 
when age and type of house were controlled for. 

In Upper-Middle Egypt only the report by Hassouma 
(1975) is available on a rural housing survey. Table 23 is 
reproduced from this report to the Egyptian Ministry of 
Planning. A majority of the houses obtained water from 
public standpipes (5^%) . However, a significant number 
(14^) had water piped to the home. For 12% of the homes, 
water came from the canals. 


Table 23 

Hater and Waste-Water Facilities in Upper- 
Middle Egypt. After Hassouma (1975). 


Water Supply 


Village 


Type of Farasicour Oueaa Deshna 

Facility - 

«%#%-#% 


Piped Inside 

36 

13.6 

4 1.6 

48 

35. 8 

Piped Outside 

106 

40.2 

194 74.6 

54 

40. 3 

Hand Pump Inside 

120 

45.4 

8 3.0 

8 

6. 0 

Canal 

2 

0.8 

54 20.8 

24 

17. 9 


Waste- 

Water 

Disposal 




Sewer 

34 

6.5 

4 

0.8 

44 

16. 7 

Septic Tank 

94 

1.8 

8 

1.6 

38 

1 4. 5 

Latrine 

134 

25.5 

219 

36.9 

46 

17. 6 

Hone 

264 

50.2 

260 

531 

134 

51.1 

Hassouma 

(1975) also 

found 

that 

6.4% 

of the 

house 


were converted to sewage systems and that 10% had septic 
tanks. These fascinating observations, especially the 
presence of the sewage systems, beg the question ”what did 
the author use as a definition of 'rural’?” Unfortunately, 
no answer was provided. However, over half of the houses 
surveyed did not have a latrine. 


in the area 

72 


between Assyut and Aswan, 


Upper Egypt: 



















only skGtchy inforinstion Gxis'ts and raost 
cGn'tGTGd on th© Aswan ©nvironni©!!t only, in 
had no sewage systeis and the large fertil 
Kiffla Company) nearby was inadequately 
wastewater which was being discharged 
(Messina, 1970). Others (Bachmann, 1965; 
reporting to the WHO found the Aswan ur 
developed in respect to wastewater management 


of what does is 
1965 Aswan City 
izer plant (The 
treating its 
into the Nile 
Satti, 1970) 
ban area poorly 


Old Nubia: In 1960 Abdady and Shalash (1966) from the 
National Research Center, Cairo, completed a one-year survey 
the Nubians which examined the environment and livestock 


based on the family 
were representative 
was a well-designed 
Table 24 shows the 


on 

resources. Selection of families was 

register at each village and selections 

and proportional to the 1960 census. It 
study. Each tribe was represented and 
number of families selected, by tribe, village, and the 
Iccation of the village on the eastern or western bank of 
the Nile. Table 25 shows the housing conditions for each 
area. Table 26 shows the type of water supply, lighting and 
food storage in the house. Whereas this table points out 
that no sewage system existed, the general description of 
the text stated that toilets were located inside the houses 
in the Fediga area, and outside for the other two tribes. 

No numbers were provided on how many were available. Also 

included in this discussion was that the hand pumpwells 
located in the Fadiga area usually did not function. 


Table 24 

Tribe, Location, Village, and Number 
of Families Selected in Nubia, 1960 
After Abdady and Shalosh (1966) 


Tribe 

location on 
Nile Bank 

Village 

Number of 
Families Selected 

Fadiga 

West 

Ballana 

275 

Fadiga 

East 

Abu Simbel 

170 

Arab 

West 

As-Sabu•a 

75 

Arab 

East 

As-Sangari 

75 

Kanoose 

West 

Sarf-Hussein 

75 

Kanoose 

East 

Kask Tamna 

75 


In 

had been 


the following villages, 
installed: 


irrigation pumps and canals 


a) 


Dikka 


73 









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74 































Table 26 

Water Supply and Lighting in Old Nubia, I960, 
After Abdady and Shalash (1966). 


Tribe 

Water Source 

Lighting 

Small 

Canals 

Nile 

Pump 

Electric 

Kerosene 

Fadiga 

94 

275 

76 

0 

445 

Arab 

0 

93 

57 

0 

150 

Kanoose 

0 

10 

140 

0 

1 50 


b) Al-Alaqi 

c) Aniba 

d) Tushka 

e) Ararana 

f) Abu Simbel 

g) Ballana 


A description of the village areas was included in the 
report. In the Fadiga tribal areas, houses were in rows 
with 20-30 meters from one row to the next, spreading out 
over a 500 by 600 meter area. Houses made of combinations 
of mud, rock, and cane were architecturally similar to the 
American Indian hogan with walls extending out to encompass 
a courtyard, a guest room, and a stable, A characteristic 
feature of Nubian houses is the decoration of the walls, 
both on the inside and outside. There is a prevailing 
attitude throughout Egypt that the Nubians are exceptionally 
tidy and honest. 

Floor plans of the old Nubian houses have been 
prepared by Fernea (1973), 

In brief, Egypt has had a progressive plan for the 
provision of a protected water supply to the rural areas 
since the ^9^Q^s. A visit to the rural areas readily 
confirms the widespread distribution of rural water supply. 
This project has probably reduced the numbers of persons 

visiting canals or unprotected water courses for their 

75 

























water^ but still evident in the rural areas 
washing clothes and dishes in the canals^ 
bathing in the canals, and the farmer irrigati 
by ancient methods requiring contact with 
Generally the sanitation conditions in the vill 
have improved somewhat since Headlee*s stud 
terms of crowding, they may have become worse. 


re the women 
the children 
g his fields 
canal water, 
ges of Egypt 
(1933). In 


76 


CHAPTER III 


MATERIALS AND METHODS 


This study is separated into two major 
The firsts termed the ^downstream study” is a 
environmental and epidemiological health 

village sites comprised of ind 
populations located downstream from the AHD^ 
relocated Nubians, The second, termed the ”Nu 
ccncerned with the Nubian populations dis 
formation of Lake Nasser, The resul 
investigaticns have been analyzed for cor 
environmental and epidemiological alterations 
the construction of the AHD. In both studies 
is guided by an operational hypothesis. 


subdivisions. 
comparison of 
parameters at 
igenous rural 
excluding the 
bian study” is 
placed by the 
ts of both 
relations with 
resulting from 
, the research 


De script ion of the 


!i2oj?Qstreaffl Study” 


The downstream study is designed to assess the impact 
of the formation of lake nasser on indigenous rural 
populations in Egypt downstream from the AHD, The design 
rationale is based on a comparative approach for which data 
axe collected from more than one site. Thus it can be 
determined whether changes occurring overtime or in a given 
location are anigue, and causal relationships can be 
developed accordingly. 


Three areas have been 
comparability. The first, 
affected by Lake Nasser, are 
city of Aswan and south of 
are Beni Suef, between the 
Sheikh^ in the north central 
convenience, the three "areas 
selected for the downstream 
Aswan, Beni Suef, or Kafr El 


selected w 
from an a 
the rural vi 
Kom Orabo. 
delta and 
Nile Delt 
” in which 
study are 
Sheikh study 


hich afford maximum 
rea likely to be 
llages north of the 
The two other areas 
Assyut, and Kafr El 
a. For the sake of 
rural villages were 
referred to as the 
area. 


In each of these three governorates, rural villages 
have been selected based on: a) how representative the 
village is of the area; b) accessibility; c) population 
composition and size; d) the presence or absence of a rural 
health center or unit. The selection of villages from these 

was also based on information obtained from past 


77 





studies. It was clear from these studies that Upper-Middle 
and Upper Egypt had frequently been excluded, with a far 
greater number of past surveys being carried out in the 
delta. Within the delta, more prevalence information on 
schistosomiasis was available for Qalyubia than all the 
other delta governorates combined. Sites in Kafr El Sheikh 
were selected, therefore, to help correct this deficiency of 
information. Also, historical data indicated that the 
northern delta, in which Kafr El Sheikh is located, had 
maintained the highest schistosome prevalence in rural 
Egypt. The data from Kafr El Sheikh provided the ultimate 
baseline prevalence for this study, as opposed to areas 
farther south and geographically, more central. Villages 
were selected in the Beni Suef area as representative of 
Upper-Middle Egypt,, for the simple reason that recent data 
indicated that the distribution of m an soni infections 

were slowly migrating south, from the Nile Delta into this 
area (Hussein, 1972, Alamy and Cline, 1977). Sporadic cases 
Ijl been seen in Beni Suef by Hussein (1 972). 

It was therefore important to determine if man soni cases 
could still be found or were increasing. 


D es cription of t]^ Study” 


This study is designed to measure the changes in the 
prevalence of schistosomiasis in the Nubian population 
following displacement due to the formation of Lake Nasser. 
The Egyptian Nubians, a population of 45-50,000 persons, 
resided in villages scattered along the banks of the Nile, 
south of Aswan to the Egyptian border. This population was 
displaced by the rising waters of the new lake in 1964. The 
Nubians, who were rural in nature and composed of three 
different tribes were moved en masse to Kom Ombo, 40 kms 
downstream from the AHD. For all practical purposes, the 
entire population was resettled in this area. The new 
villages bear the same names as those from which the 
settlers originally came and, in addition, retain their 
respective locations as in old Nubia with the Kanoose tribe 
in the north, the Arab in the middle, and the Fediga in the 
south (See previous Figure 11). No other formal arrangement 
was made by the government to have resettlements in other 
areas. However, there remains an original Nubian community 
located on the eastern Nile bank, just north of the old 
Aswan dam, called Kazan Sharg. This is the southernmost 
village in Egypt with the exception of a very small village 
located on an island in the reservoir that inundates the 
area between the old and new dams. No resettlement sites 
are present on the lake shore. The high ground surrounding 
the lake is harsh, barren, and, according to Dazo and 
Biles's (1971) survey, uninhabited, with the exception of 
the Abu Simbel community 300 kms upstream from the AHD. 

78 




Although Ab 
community ^ 
currently i 
was 134 an 
employed in 
Simbel does 
is the only 
of the cu 
Observation 
Way^ 1977 c 
of Literatu 
population 
helminthic 


u Simbel does not constitute a rural/agricultural 
it is the only permanent lake shore site 
nhabited. In 1971^ the population of Abu Simbel 
d was comprised mostly of government workers 
the maintenance of the Abu Simbel temples, Abu 
not represent displaced Nubian communities^ but 

could possibly give an indication 
conditions at the lake shore, 
five-day trip on Lake Nasser in 
findings. Earlier in the Review 
re, Dazo and Biles (1972) found that 9% of the 
there had S^ h aema tobium infections. No other 
infections were observed. 


location that 
rrent health 
s made during a 
cnfirmed these 


The Nubian study includes three major sites between 
which comparative studies have been made: a) the old, no 
longer existing Nubian villages of Kurta, El Malki, and 
Ballana; b) the correspondingly resettled sites at Kom Ombo; 
and c) the original Nubian community, Kazan Sharg, located 
on the eastern Nile bank just north of the old Aswan Dam. 

Abu Simbel had to be excluded because it does not 
represent the Nubian population. Also excluded are the lake 
shore sites which are yet to be developed, and the Lake 
Nasser fishermen. As mentioned previously, a joint WHO-EHH 
inter-region project (lR-065 RDF/71/217) is currently being 
organized to investigate the health status of the Lake 
Nasser fisherffac population. 




The working hypotheses from which the survey design 
has been developed are: 

1) The Downstream Study; There are significant 

increases in the estimated prevalence of 

schistosomiasis due to the construction of the 
Aswan High Dam and related irrigation expansion in 
the sample of the selected sites located in the 
Nile Delta, Upper-Middle, and Upper Egypt. 

2) The Nubian Study; There are significant increases 

in the estimated prevalence of schistosomiasis due 
to the construction of the AHD and related 

irrigation expansion in the sample of the selected 
sites located in the resettled Nubians in Kom Ombo. 

Definitions for pre— and post— AHD are needed to 
establish the point in time for describing ‘before* and 
•after* conditions necessary for making comparisons between 
studies. Pre-dam is defined as the period before the 

discharge of the Nile was controlled by the AHD, Post-dam 

7 9 




is defined as the period frota 1964 to the date of this study 
(1976). The construction of the AHD was not completed until 
1974y but as mentioned earlier, the coffer dam, constructed 
to divert the flow of the river around the area where the 
AHD’s foundations were being laid, was removed in 1964 and 
the ensuing floods have since been trapped behind the AHD. 
The reservoir reached maximum volume in 1976. The term 
**significant” is defined as a meaningful increase in the 
prevalence of schistosomiasis when comparing the results 
from different study sites used in this research with 
results from other villages employed by other workers. 
Frequently, the number of cases is large enough to 
demonstrate statistical significance between results 
differing only in one or two percentage points. Whereas 
this would constitute statistical significance, it would not 
be meaningful. Faroog, et al., 1966, and others (Bell, et 
a l, , 1967, Gilles, et 1973) have shown that on the 
average, the variation in prevalence of schistosomiasis 
from one Egyptian village to another is about 10 to 12 
percentage points. This is a considerable amount of 
variation and is due principly to the focal nature of 
schistosomiasis distribution which has been consistently 
demonstrated since the earlier studies. Therefore, a 
significant or meaningful increase (or decrease) would 
require at least a difference of 10 percentage points. 


Data Acquisition 


The two major categories of data collected were: 
historical baseline data and data collected from field 
studies that included environmental health data and 
epidemiological morbidity data for schistosomiasis. The 
iBplementation cf the field survey was guided by a program 
evaluation review technique (PERT) diagram. 


The PERT diagram identified and numbered each 
individual activity or job to be carried out. The time in 
days required to complete each job was estimated and then 
each job was placed appropriately in the sequence. Except 
for the first, each preceding job or jobs had to be 
completed before the following one could be started. Thus, 
projected dates of completion were calculated. Moreover, 
free slack, or the axount of time that a previous job could 
be postponed without delaying the overall projected 
completion time, was estimated. The estimated time to 
complete the field activities up to the point of analysis of 
the data were 256 days. The actual time for completion was 
approximately 260 days. 


80 








i£§cific Da^a Collected 


The categories for data which were collected are: 

1) ©nvirojunental health paraiaeters: 

a) water supply and use 

b) sewage disposal 

c) housing 

d) irrigation practices 

2) epidemiological paraiaeters: 

a) age-sex structure of the sample population 

b) schistosomiasis prevalence* 

It may be noted that agricultural irrigation methods 
have teen included as an environmental health parameter* 
Generally^ irrigation schemes, as such, do not fall within 
the realm of environmental health specialties. However, in 
Egypt as in a number of other tropical developing nations, 
agriculture practices and especially irrigation methods play 
a central role in the transmission of schistosomiasis. 
Moreover, it is the open canals and drains which are 
associated with present-day irrigation in Egypt that provide 
excellent habitats for snail vectors. For the rural 
populations of Egypt, canals long ago became a way of life. 
The convenience the canals have provided in the rural 
villages for domestic water for washing, bathing, swimming, 
drinking, and ablutions is readily evident to the visitor. 

Data acquisition forms (questionnaires) were designed 
and translated into Arabic. These forms serve as a list for 
the various parameters under study. The original English 
data forms are included in Appendix 2. 

The environmental health parameters are a critical 
measure under study. However, the environmental parameters 
not directly associated with water use require some 
explanation, e.g. housing. Housing is an important 

indicator of the level of sanitation, which is an important 
variable in this study. The level of housing conditions 
also serves as an indication of environmental changes in the 
resettled areas in the Nubian study. 

Considerable peripheral data are included in the 
survey listed on the data forms. As much data as possible 
were obtained concerning all the environmental parameters in 

the hope that nothing would be overlooked simply because it 

81 



was not requested. Secondly^ data were needed to control 
for certain variables; for example age, sex, occupation, 
etc. Indeed, the study was originally designed under a much 
broader scope specified by the needs of the River Nile-Lake 
Nasser study of which this work was a part, 

i§i£ction of Field Jurvejj Sites 


A total of ten health units and centers were selected 
in Kafr El Sheikh and in Beni Suef based on criteria 
mentioned in the description of the downstream study. The 
name of the health unit or center does not always correspond 
to the name of the village from which the sample population 
was selected. Sometimes more than one village was sampled 
by the health unit or center. This is true also for Aswan 
and for the Nubian sites. 


In Kafr El Sheikh the selected health units or 
centers, also termed "study sites”, and their code numbers 
were: 


(a) 

healt h 
Agazein 

unit El Agazein 
was sampled; 

(16) : 

only 

the 

village El 

(b) 

health center El Hamra 
Hamra was sampled; 

(17) : 

only 

the 

village El 

(c) 

health 

fiahalet 

unit Wahalet El Kasab 
El Kasab was sampled; 

(18) : 

only 

the village 


(d) health unit Wahalet Mousa (19): Mahalet flousa and El 
Nataf were sampled; 

(e) health unit Sheno (20): two villages, Sheno and 

Reskit El Shenawi, were sampled. 

In Beni Suef, the selected health units or centers and 
their code numbers were: 


(a) health center Barout (11): only the village 

Earout was sampled; 

(b) health unit Sherif Pasha (12): only the village 
Sherif Pasha was sampled; 

(c) health unit Naiia (13): two villages, El Amrana 

and Abu llousa were sampled; 

(d) health center Beni Adi (14): only the village of 
Beni Adi was sampled, 

(e) health center Ashamant (15): only the village of 




Ashamant was sampled 


Both Kafr El Sheikh and Beni Suef are the respective 
capitals of their governorates. Kafr El Sheikh is about 2.5 
hours* drive north of Cairc^ roughly 140 kms/ and is located 
in the central northern sector of the delta. The northern 
border of the Kafr El Sheikh province is the Mediterranean 
sea. Almost the same distance to the south of Cairo is Beni 
Suef. To the north of Beni Suef is Giza; to the west, the 
Fayoum; and to the south, Minya. Each of the villages 
selected in both Kafr El Sheikh and Beni Suef was an 
agricultural community typical of the area. 

In Aswan the selected health units or centers and 
their code numbers were: 


(a) health unit Kazan Sharg (1) : the village of 

Kakhor was sampled; 


ib) 

health 

unit 

Guzaria 

(2) ; 

the 

villages Gam 

ma. 


Osrob, 

and Harrob were 

sampled; 



(c) 

health 

center 

Abu Bish 

Bahri 

(3) : 

the villages 

of 


Mai Katta and 

Mai Licta 

were 

sampled; 


(d) 

health 

unit 

Ga* afra 

<4) : 

the 

villages of 

El 


Aratag, 

S houna 

Masagien, 

Falaleha, Omarab, 

Ali 


Abu Kariae, El Sheikh Garat, Hedadoun, Hagar, and 
Hahatta were all sampled; 

(e) health center Bimban (10) : the villages of 

Kenisa, Abu Shari, Omda, Mariab, Sheikh Mousa, and 
Kabarra were all sampled. 

In the Nubian resettlement area of Kom Ombo, the 


selected 

were: 

health 

units or 

center 

s and 

their code numbers 

(a) 

healt h 
Ballana 

center 
1,2, and 

Ballana 

3 were 

(5) : 

sampled 

the villages of 

• 

(b) 

health unit Tushka (6) : 
was sampled; 

only 

the village Tushka 

(c) 

healt h 

center El 

Malki 

(7) : 

only the village of 


El Waiki was sampled; 


(d) health unit Kurta (8): only the village Kurta 2 

was sampled; 

(e) health center Kalabsha (9): the villages Kalabsha 
and Abu Khor were sampled. 

The location of the different 

83 


selected sites in the 


Aswan study area can be seen on the sketched map given in 
Pigure 14* The village of Kazan Sharg (1) is one of the 
most southern villages to be found in Egypt. This village 
is comprised of Nubians of the Kanoose tribe, and it should 
be pointed out that Kazan Sharg (1) and a few remaining 
villages just to the north, are also populated by Nubians 
who, because of their location downstream from the AHD, did 
not have to be moved when Lake Nasser began to fill. Rather, 
this small population of Nubians are living in the same 
villages and the same homes that they were living in before 
the AHD was built, or, for that matter, from the last 
century and before. 

The villages located at health units and centers 2,3, 
and 4 are communities typical of the area between Aswan and 
the Kom Ombo plain and are located on the eastern bank of 
the Nile. These communities are characteristically found on 
high, dry, barren ground. Because the Nile Valley is so 
narrow in this area, very little land is available for 
cultivation, and, therefore, what is available is far too 
valuable to build on. The cultivated areas are always found 
as a green strip between the village and the river, with the 
exception of Hagar in Ga'afra, which is located on a lew 
barren hill next to the river. In this respect these 
villages are unlike the ones in the Kom Ombo agricultural 
plain. From the northern point of the Kom Ombo plain, 
continuing north, the narrow valley gradually begins to 
widen as it passes through the next two governorates, Qena 
and Sohag. In these sites the villagers live at a greater 
distance from the irrigation canals and drains than 
villagers located in the delta or in Upper-Middle Egypt. 
Villages are found within the cropped area with increasing 
frequency as one travels north and east of Aswan into Qena 
and Sohag. North of Sohag only a small fraction of the 
rural population resides in villages located outside the 
cultivated land, and these villages are often bounded on one 
side by their fields. The health center Bimban (10) , was 
selected to represent villages typically built within the 
cultivated area. Six different villages all located in 
Bimban ma^kaz (center) were sampled. The Bimban marka z. 
seen on the map in Figure 11, is located on the western bank 
of the Nile Valley almost directly west of Daraw. The 
villages are separated from the Nile and from the desert to 
the west by fields of sugar cane and wheat, and by palm 
groves, etc. 

The selection of the Nubian resettlement villages was 
based on the previous study by Zawahry (1964). Each 
village that was surveyed in 1964 has now been surveyed 
again for this study. They are Ballana (Fadiga) (5), El 
Walki (Arab) (7), and Kurta (Kanoose) (8). In addition two 
other villages were selected: Tushka (Fadiga) (6) and 
Kalabsha (Kanoose) (9), to increase the overall sample size. 

84 






Figure 14. This is a sketch map of the Korn Qnbo area showing the 
distribution of health units and centers. Also shown are the 
study site locations for this area, which are represented by the 

shaded units. 


85 




Data Collection Teams 


The primary data collection teams at each of the 
selected health units or centers were comprised of a 
physician, a laboratory technician, a sanitarian, one or two 
nurses, and one or more aides. The team was led by the 
physician whose responsibility was to implement the 
collection of data and to ensure that all activities were 
completed according to the outlined procedures (see Appendix 
4), The cooperation and employment of the various health 
teams was obtained through the Egyptian Minister of Health 
and through the respective regional offices of the director- 
general of health. The director-general provided 
transportation to the sites and local security approvals, 
and saw to it that the materials necessary to continue were 
received at the study sites. In addition, a field 
supervisor, typically a vice-director-general, was assigned 
to follow the day-to-day progress in the field and to work 
closely with the technical field supervisor (the writer). 
Aside from developing the plan of operation, acquiring 
materials, and training personnel, the role of the technical 
field supervisor was to coordinate the work at all levels at 
each of the twenty field sites. 

The Egyptian Minister of Health assigned Dr, Baha 
Hashen, the director-general of all rural health services as 
a team representative from the ministry to the project. The 
EHH*s services proved to be very helpful in establishing 
communications, transporting materials, collecting data, and 
obtaining cooperation of primary data collection teams. 

The chief administrative team leader. Dr, M. Hussein, 
Dean of the High Institute of Public Health at the 
Oniversity of Alexandria developed the administrative 
structure by which the various data teams and members were 
employed and paid, and closely followed the day to day 
developments in the field. In addition. Dr, Hussein 
obtained the necessary governorate approvals and security 
permits and provided the laboratory space and personnel for 
the analysis of the stool and urine specimens at the 
University of Alexandria. 


Hev iew of Facil iti es an d Preparation of Material 


The location for the examination of families was a 
rural health unit or a rural health center. Each health 
unit (for outpatients only) and each health center (small 
scale in-patient facilities available) selected was assessed 
for facilities needed for the survey. If facilities or 
equipment were lacking, they were obtained by the local 
field supervisor from the respective director-general’s 









office. For the most part these services were not needed as 

the health units and centers selected all had the required 

facilities and were in working order. These facilities 
included: 

(a) a light microscope, monocular model, with at least 
low power (16mm focal length) and high power (4mm 
focal length) objectives, and related equipment - 
slides, etc. Often these were manufactured in 
Czechoslovakia and were similar to Japanese Nikon 
models. 

(b) glass pipettes in sufficient quantity 

(c) 250 cc glass conical flasks for urine 
sedimentation 

(d) stool pans for the collection of stool specimens 

(e) a hand centrifuge 

(f) a balance for determination of weight and height 

The balances were made by Detecto Scales, Brooklyn, 
N.Y., O.S.A.; model Detecto-medic or similar. Microscopes, 
balances and hand centrifuges were placed in the health 
units and centers by UNICEF about 5 years previously in a 
program to update rural medical facilities in Egypt. 

The additional materials needed by the health units or 
centers for the recording of data and preparation of 
specimens were: 

(1) printed data forms in Arabic 


( 2 ) 

(3) 

(4) 

(5) 


solution for preservation of 
specimens 

10 cc plastic specimen vials or 

disposable applicator sticks 
stool specimens 

permanent felt-tipped ink pens 
bottles 


stool and urine 

bottles 

for transferring 
to label specimen 


(6) a reference or methods guide for the correct 
procedure to be followed during the survey 

Printed data forms: the data forms for the clinical 
examination of the family, form code 01. and the data form 
tor the examination of the house, form code 02. were first 
translated into Arabic at the High Institute of Public 
Health. The same procedure was used for the environmental 


forms coded 03 through 12, (All data forms and the methods 
guide are included in Appendix 2 and Appendix 3, 
respectively.) The translated forms were reproduced by 
mimeograph. At the beginning of the field activities all 
forms were reproduced at the High Institute of Public 
Health. Over 8,000 forms of 01 and 02 were necessary. Form 
01 had three pages and 02 had four. Therefore, 56,000 
sheets of paper were reguired just for these two forms. It 
scon became obvious that delays would develop if the forms 
continued to he mimeographed at the High Institute. Paper, 
stencils, and staplers were purchased and delivered to the 
local director-generals* offices, which took over the 
responsibility of providing printed forms. 

Data form design: the data forms for the examination 
of the family were based in part on the studies by Farooq 
and Nielsen (1966), Zawahry (1963), and Hussein (1972). At 
each health unit a guide for the correct completion of the 
data form from the examination of the family was provided. 
This guide also included the correct method by which all 
procedures were to be carried out for the collection of 
field data. The guide served only as a reference and was 
not a substitute for instruction. 

It should be pointed out, however, that special 
procedures were taken to determine age. The determination 
of age in a highly illiterate population is prone to error. 
Measures to minimize errors were adapted from Scott (1937). 
Scott (1937) found that it was more accurate to place a 
person in an age-group than to estimate the person*s exact 
age. An age group sheet of 5-year age groups (starting from 
0-1) was distributed with the methods guide and instruction 
for use was given to the physician. Birth dates were 
recorded only when government identification cards could be 
provided. 

An attempt was also made to determine what medication, 
if any, the individual had taken in the 360 day period prior 
to the day of examination. Only medications for parasitic 
diseases were recorded. Other medication received was 
recorded as ’’ether”. Details for the methods of obtaining 
the remaining data and data for the housing are described in 
the methods guide. 

The design for the housing form code number 02 was 
adapted from Mitwally and Shargawi’s (1970) article on 
measuring housing conditions in the rural areas of Egypt. 
For each data form a clear plastic overlay sheet with an 
English translation was made. These clear overlays provided 
an instant translation of the Arabic data form into English. 
As a guideline, the house to be examined by the sanitarian 
was defined as ”the area lived in by the selected family”. 


88 


El§servation of Stool and Urine Speci men s 


It vas clear from the beginning that there was 
considerable variation in ability to examine stool specimens 
for parasites and ova between laboratory technicians at the 
selected health units and centers. To compensate for the 
undesirable variability and to maximize the comparability 
from one study site to another all stool specimens were 
preserved and sent to the laboratory at the High Institute. 
At the "central laboratory” the specimens were examined by a 
staff of trained personnel. 


To implement this central approach for the examination 
of the specimens^ a 10 ml translucent polyethylene bottle 
was provided for each individual at the selected sites. 
These bottles were purchased in Cairo and were 2 cm in 
diameter, 5 cm tall with a 1 cm opening in the top for which 
there was an inner cap and an outer screw cap,all 
polyethylene. On each bottle the code number of the 
individual, comprised of the health unit number, the family 
code number, and the individual's number within the family 
and his or her name were written with black, permanent, 
felt-tipped pens. Both pens and bottles performed well over 
the period of the survey. There was no occasion when the 
label came off, and the bottles, which were unbreakable, did 
not leak even though an occasional screw top had been 
deformed during the molding process. 


The procedure for collecting the stool and urine tor 
preservation is outlined in the methods guide. Two points 
should be added. One, that the urine specimens were 
examined at the health units by the laboratory technicians. 
In addition, two drops of urine sediment was added to the 
stool specimen for preservation and examination later at the 
cehtral laboratory. In this way a double check was provided 
on the examination of urine. The results of the on site 
examination were recorded on the data form for the 
examination of the family, form 01. Two, the transfer of 
the stool from the stool pan to the specimen bottle and the 
mixing of the stool with the preservative solution required 
something cheap and disposable. Broom straws, along with 
matchsticks and toothpicks, were all tested unsuccessfully. 
Very commmon in Egypt are small vegetable crates made by 
hand from palm fronds. The ribs of these crates were found 
to split nicely into straight wooden sticks which easily 
transferred and mixed the specimens. For preservation, the 
stool was mixed with 9.0 to 9.5 cc of merthiolate-formalin 
solution adapted from the merthiolate-iodine-forraalin 
concentration technique (flIFC) (Blagg, et al^, 1955). Ova, 
cysts, and trophozoites in fresh stool specimens collected 
in the MIF solution have been successfully preserved without 
deterioration cf descriptive cytological features for a 

number of years. The exact period before deterioration 

89 




begins is under study at the Naval American Medical Besearch 
Unit (NAMRU-3) in Cairo where the technique was first 
developed. Instead of adding iodine (Lugoi*s iodine) at the 
time of preparation when the specimen was mixed, as 
prescribed by this technique, the Lugol's iodine was added 
afterwards at the central laboratory just before the ether 
extraction phase. This alteration in technique, in addition 
to the fact that approximately 0.05 ml of urine sediment was 
being added, did not interfere with the desired staining 
intensity. By delaying the addition of Lugol's iodine at 
the health unit or center, the amount of materials that had 
to be delivered was reduced. This also assured that the 
Luqol*s solution used was fresh, as it begins to deteriorate 
as a stain after one week. Thus the urine was examined 
twice, once at the health unit or center and once at the 
central laboratory. 

Examin ati on of Stool and Urine S pec imens 


All specimens were 
sites and transported to 
High Institute of Public 


collected from each of the study 
the parasitology laboratory at the 
Health. At the laboratory, a team 
comprised of nine physicians examined the specimens. The 
team was supervised by three senior lecturers of 
parasitology at the High Institute. 


All specimens received at the laboratory from a 
particular health unit or center were grouped together. 
There was no intended order within the group and a few 
specimens at a time were selected for examination from each 
group. This quasi-raodom method helped minimize the biasing 
effect of individual ability among the laboratory personnel. 

The preparation of a specimen for examination was as 
follows: 


1) the specimen was mixed and poured through a layer of 
wet gauze into a labelled centrifuge tube. 

2) 0.6 ml of fresh Lugol*s iodine was added to the 
specimen. 

3) 4 ml of petroleum ether added in order to increase the 
specific gravity of the ova and cyst by extracting the 
lipid fraction. The tube was inverted and shaken 
vigorously. 

4) the specimen was centrifuged for 5 minutes at 1500 rpm. 

5) the top ether layer and fecal plug, and MIF layer were 
removed by suction, leaving the sediment and about 0.1 
ml of BIF solution on top of the sediment. 

90 




6) the sediment was resuspended and a drop of this mixture 

placed on a microscope slide^ and covered with a cover 
slip. 

7) the slide was examined for characteristic ova, cysts, 
and trophozoites. 

8) results were entered on a coded specimen examination 
form, an example of which is shewn below. 

Stool exa minati on form JCode _5h 

Specimen vial number 

Date 

Helminths 


Ascaris lumbricoides....................1 

Trichuris trichiura............................2 

Enterebius vermicularis...3 

Ancylcstoraa duodenaie..........................4 

Strongyloides stereoraiis......................5 

Taenia sp. ....................................6 

Trichostrongylus sp. .......................... 7 

H« nana... .....8 

H. h€t€rophyes...............................,,9 

F. hepatica...................................10 

F. gigantica....11 

S« haematobium.*...12 
S. mansoni. .. .13 

Protozoans 

Giardia lamblia...........14 

£. histolytica....15 

E« CO li.«...••». ...•*••...•.....16 

E. hartmanni............17 

Iodamoeba butschlii18 

End o Umax nan a... .19 

Chilomastix mesnili............••.•••.........20 

Trichomonas hominis........21 

Dientamoeba fragilis..... 22 


Examined by. 

The coded specimen form includes a place for the code 
numbers, date, form code, and code number of the examiner at 
the laboratory who examined the slide and places for 
indicating the presence of the various parasites screened. 
Only one slide for each specimen was examined. 

An in-laboratory test was used to obtain data on 
individual examiner error. One specimen each day was 
examined by all members g-j and the results scored 




























independently. It was requested that the personnel examine 
the ”test” slide in the same fashion as all other slides. 

were not shown to the personnel, and it was 
this was a procedure to estimate error 
proficiency examination* All laboratory 
High Institute were closely followed and 
the identification of the various 
ova are easy to identify as they 
very characteristic in morphology, 
by comparing sample specimens with 


The exam results 
emphasized that 
rather than a 
personnel at the 
exhibited proficiency in 
parasites. The helminth 
are generally large, and 
Proficiency was assured 
the NAMRU-3 laboratory. 


An examination of the urine specimens for schistosome 
ova was also completed at the health unit or center’s 
laboratory. The method used was the simple and classic 
sedimentation technique. This is the same method most 
commonly used in screening procedures where large numbers of 
specimens have to be examined and is described by Farooq and 
Nielsen (1966). Briefly, urine is placed in a 300 ml 
conical flask and left undisturbed for 30 minutes. The 


sediment is then transferred to 
scanned for ova under low power- 
used in Egypt for a long time, 
technicians at the health units 
retrained and many were eager to 
Nevertheless, the physician was 
insuring that correct procedures 


a slide, covered, and 
This technique has been 
None of the laboratory 
or centers had to be 
display their skills, 
placed in direct charge of 
were adhered to. With one 


exception, there was never an occasion when the results of 
the laboratory technicians were in question. The one 
exception, in Bimban (10) , is elaborated on in the Results. 


Selection of the ^mple Popul ati on 


A systematic sample was 
unit of selection was the 


taken at 
family. 


The 
each 
s ite 
list 
that 


each study site. 

All members of 

family in the sample were examined. From each study 
about 200 families were selected systematically from a 
drawn up from the village or villages to be sampled 
included all the families of the village or villages and all 
the members of each family. By selecting 200 families per 
health unit or center, a sample total of approximately 700 
to 900 persons was estimated. The target sample size for 
all study sites in both studies was between fourteen and 
eighteen thousand. The family list was the sampling frame. 
For purposes of selecting the sampling unit (the family), 
the family was defined as a man, his wife or wives, and all 
unma rried offspring. This definition was easy to use and 
fairly stable, i.e., the average number of persons per 
family did not vary greatly from site to site, though in 
Upper Egypt the families were somewhat smaller. (Note that 
not all offspring of a selected married female may have been 

examined.) All selected family members were accounted for. 

92 






If a member did not attend the examination, an explanation 
of why the member was not present was stated on the family 
examination form. No attempt was made to replace those who 

would not come, were absent at the time of the survey, or 
had died. 

To make the selection of the families, an up-to-date 
list of family names and members, or sampling frame, was 
required. Generally a frame was available but often out-of- 
date by four to five years. in order to avoid delaying the 
start of the survey, the following procedure was 
implemented. The total number of families in the old list 
was divided by 200. The number obtained, for example 3.4, 
was rounded off to the next higher number and added to one 
{2 or 3 in ether cases depending on an estimate of how many 
new families would be added)• In this example, with a 
starting list of 680, every fifth family would be selected 
starting from a random number between 1 and 5. The frame 
would immediately begin to be updated, adding new families 
at the end of the list, and the examination of the selected 
families starting from the first selected and proceeding 
sequentially was also begun. The up-dating was always 
finished long before the examination of the first selection 
of families could be completed. The selection of every 
fifth family according to this example would result in an 
under-selection, i.e. less than 200 would be selected. In 
this case about 136 families would be selected if 120 new 
families were added to the original list of 680. After the 
examination of 136 families, 64 families would have to be 
reselected from 664 remaining unselected families by 
selecting every 10th family. Eeselection being made without 
replacement, a total of 202 families would be selected and 
examined. This approach was used throughout the study, with 
two or more samples (one or more reselections) from each 
site being taken in this fashion. Each selected family was 
circled and serially numbered in the list of family names 
and members. 

The serial number for the family became the serial 
code number for that family. The members of the family were 
listed serially starting with the first person examined on 
the family examination data, form 01. This gave each 
individual that was examined in the survey a unique code 
number comprised of the numner of the village, the family 
serial code number, and the individual code number within 
the family. The code number 01,001,01 identifies the first 
person in the first family selected at the health unit 01, 
Kazan Sharq. The health unit or center code number and the 
family serial code number were used to identify the data 
forms 01 and the housing data forms 02. The data form, 02, 
was completed for each house of each of the selected 
families. These forms were matched with the family 01 forms 
by coding the 02 forms with the health unit or center 
number, the house number, and family serial code number. 



The same sample size (200 families) was used throughout the 
survey^ rather than selecting a given proportion of the 
population at each site* Therefore, the sampling fraction 
varied from site to site. This was done for administrative 
reasons, and because it was desired that the completion of 
the survey of the families and the environment be roughly 
during the same period of time at all sites. The reason for 
this was that by carrying out the survey at the different 
sites over the same period of time, the possibility of 
seasonal variation of the parameters measured between the 
sites would he negated. 


It was estimated that 200 families would yield a 
sample of about 800 individuals. This sample size was felt 
sufficient to give the estimates of the various parameters 
sampled with adequate precision at each site. The 
systematic selection of families was used as opposed to a 
purely random method for two reasons. One, the systematic 
selection more often than not gives greater precision. With 
a systematic selection, no isolated groups, individuals, or 
houses are left unrepresented in the sample, as might 
inadvertently happen with a random selection. Two, the 
selection of the families for examination could proceed 
immediately without waiting for an up-dated family list. A 
random sample would be impossible to select before the list 
was completed because the added group would not have a known 
possibility of being selected in the first round. 

Examination of tte Snyi ron ment and the P opul ation 


Before the survey could begin, each health unit or 
center had to receive the necessary materials and the 
personnel had to review the methods for the correct filling 
in of the data forms and the correct method for preparing 
the stool and urine specimens. The up-dating of the family 
list was always the first activity, followed by the 
selection of the families. In order to obtain the 
cooperation of the village members, a meeting was held with 
the village council, the local physician and the field 
supervisor, to explain the purpose of the survey and solicit 
the aid of the council to overcome any difficulties. On 
occasion the director-general of the governorate attended 
these meetings. Only after the personnel at the health unit 
or center showed proficiency with the different aspects of 
the data acquisition was the examination begun. 


Generally a routine was established where the 
sanitarian would go to the selected family^s house, complete 
the housing form and instruct the family to go to the health 
unit or center the following day. The instructions included 
telling the family members that the information obtained 

would be held in strictest confidence and that specimens of 

94 





stool and urine would be requested at the health unit or 
center. At the health unit or center^ the selected family 
members would be qiven a numbered stool pan and a numbered 
tin cup and requested to provide a specimen of each at some 
point during the examination. 


By obtaining the specimens from the selected family 
members at the health unit or center, proper identification 
of the specimens could be guaranteed. This is a unique 
feature to this survey. Scott (1937)^ Farooq and Nielsen 
(1966) , and Zawahry (1963) all obtained their specimens by 
providing speciaen containers to the heads of the household 
of each of the families selected. 


There were exceptions, most notably at Kurta (8) in 
the resettled Nubian area. The water supply in the 
laboratory at Kurta (8) was the most inadequate of all the 
selected sites. The piped water supply was limited to a few 
hours a day and frequently failed for periods longer than 
48 hours. Water rarely came to the health unit’s 
laboratory. At Kurta (8), protected water was used first 
for drinking anc cocking before it went for other purposes. 


Because of this lack of water at the health 
unit,selected family members refused to give stool 
specimens. Under the circumstances, the methods of Scott 
(1937), Farooq (1966), and Zawahry (1964) were employed. 
Thus the correct specimen was obtained. Also, a large metal 
reservoir was given to the health unit laboratory so that 
water could be stored and available to clean equipment. 


Trips to the field to initiate the survey activities 
were made in early April, 1976. By May, 1976 all units and 
centers had begun the collection of data. After the survey 
had begun, each field site was repeatedly visited. During 
these visits, additional materials were supplied, completed 
data forms and prepared specimens were picked up, and, if 
required, a reselection was made. In addition, a survey 
progress evaluation was made. This evaluation included the 

following: 

1) a check to see if the names on the completed 01 and 
02 forms corresponded to the names in the family 
list. 


2) a check to see if the correct code numbers were 
being used. 

3) a check to see if the code number on the specimen 
bottles corresponded to the code number on the 
faffily form 01. 

4) a check to see that the housing forms 02 were being 
correctly completed. This was done by selecting 


several coopieted forms and going to the respective 
homes and seeing if the completed forms agreed with 
the actual conditions. 

a check to see if all the families in the village 
were included in the family list. This was done by 
going to the village and randomly selecting a house 
to see if the occupants were listed in the book. 
On no occasion was a family located that had not 
been included. It should be pointed out that^ one, 
the sanitarians are well-trained in this respect; 
and two, they were often residents of the village 
who knew the villagers well, and were actually 
related to many of them. 

to review any problems or obstacles being met and 
to resolve them. 


to review the general progress, and to determine if 
the health unit or center was on schedule. Since 
only part of the working day could be allotted to 
the examination of the family members or the 
environment at the health unit or center, it was 
requested that approximately 20 persons per day, or 
five to six families, be screened at a time. The 
examination of the families and their environment 
at each site which was to be completed in about 
three months was actually 95% complete after five 
months. 


to review the method of examination of the selected 
family members. This was done by observing the 
completion of the family form 01, with the 
physician at the health unit or center during a 
visit when examinations were being carried out. 
First, a family that had been examined just prior 
to arrival was recalled and re-examined, while 
checking the completed form for discrepancies. 
Secondly, the completion of the family form was 
followed through on a family who had not been 
examined. This was especially helpful in detecting 
errors in obtaining and preparing specimens. 
Idiosyncratic procedures were noted during this 
time. Those which did not in themselves affect the 
collection of data were usually allowed to 
continue, as changing procedure would risk causing 
errors. 


confirmation of the methods used at the health unit 
or center for completion of the environmental data 
forms were reviewed in the same fashion as were 
employed for checking the housing forms. 

on occasion, persons or families would come to the 

96 




health uait or center requesting to be included in 
the examination, if the person «as elderly and a 
relative of a selected family or a village leader 
vho had not been selected, forms viere completed and 
specimens taken. No code numbers apart from the 
health unit number were given to these individuals. 
Data from these forms were not included. 

11) an inventory of all the materials. 



one of the most important checks wa 
specimens of stool and urine 
examined, prepared, and labelled, 
first it was stressed that the righ 
right urine be placed in the righ 
correct manner. (The correct 
O'lflined for the laboratory technici 
This procedure was reviewed freq 
health units and centers at the time 
were being provided by the selected 


s to see if 
were correc 
From the v 
t stool and 
t bottle in 
procedure 
ans in Arabi 
uently at 
when specim 
individuals. 


the 

tly 

ery 

the 

the 

was 

c.) 

the 

ens 


P at a Management 


^5^ Analxsis 


For this study, 3859 house data forms were executed 
for the examination of the dwelling units. An almost equal 
number were completed for the examination of the family. 
About 400 data forms were completed for the various 
environmental aspects of the village sites. Exactly 15,665 
stool specimens were received. Ultimately, over 40,000 
cards were keypunched. 


When raw data in these quantities are obtained, major 
efforts have to be made to keep the data from being 
misplaced, lost, or damaged before it can be processed. 
This was aggravated by the distances involved between the 20 
different study sites, as well as by the lack of good 
communication systems. Invariably staff at the health units 
faced problems after actually starting the survey that were 
not anticipated daring the training phase. Most often the 
problem was solved by a change in coding procedure which did 
not affect the final accuracy. For example; on the housing 
form (02), in an unanticipated situation, the correct answer 
required the selection of more than one number, although 
only a single answer had been anticipated, and only one box 

data form. The examiners simply 
whatever the combination may have 
This alteration was easily handled 
when the coding sheet was designed. The process was not 
always as uncomplicated as this and new combinations 
necessitated redesigning the code sheets. 


had been provided on the 
wrote in two numbers, or 
been, in the given box. 


To minimize problems 


of data 

97 


management, a complete 




inventory of the number and amount of materials delivered 
and received from each study site was kept. Before data 
forms were accepted, they had to be checked for 
ccmpleteness, consistency, and accuracy. 

All ccmpleted forms were packaged and delivered to the 
Cairo University Statistics Center. Code sheets were 
designed, tested, and re-designed. The final coding sheet 
for a particular form was reproduced at the center by offset 
printing. 

Before transferring the data onto code forms, a code 
bcok or code key was developed for each type of data form. 

The questions on the family examination form 01 concerning 

diagnosis ard medication received were the only examples of 
truly open questions, and required continued updating of the 
code book. The greater part of the coding was simply 

copying a selected number onto the code sheet. 

Coded data were verified on a sample of forms from 
each site before punching. Punching formats were designed 
from the code sheets, i.e., data were punched directly from 
the code sheet. At the computer center printed listings of 
each site were made and checked against a sample of original 
data forms. For listing the data on magnetic tape, the 

punched cards were sorted by site, family, and individual, 
and a file cn magnetic tape was created for each category of 
data fora. 

A series of Fortran IV programs were written at the 
Cairo University Statistics Center for use on a Bata General 
•Nova* computer. These programs were for: 

1) preparing listings of various sub-sets of data. 

2) basic tabulations of important variables in the data 

set. A number of tabulations were used to follow the 

work in the central laboratory, and were designed 
specifically to detect errors and inconsistencies made 
by the labcratory workers. 

3) sequencing, matching, and renumbering of specimen data. 

4) validating and examining the consistency of coded data. 

5) eliminating duplicates in the specimen data. 

6) writing the data set onto magnetic tape files. 

The complete data set stored on magnetic tape was 
transferred to the University of Michigan’s computing center 
for continued analysis. At the University of Michigan the 
Michigan Terminal System (MTS) and the Michigan Interactive 
Data Analysis System (MIDAS) was used to: 




1) re-edit various sub-sets of data based on the results 
of verification programs run in Egypt. 

2) match and merge the data from the family examination 
nith the data from the specimen forms and housing forms 
for the creation of a master data file. 

3) to complete^ following step number two, the descriptive 
analysis and the assessment of relationships between 
variables in the data were completed. 

Adjustment Scheme 

Since the sampling fraction and the age structure of 
the sample varied from study site to study site, an estimate 
of prevalence made by simply adding together ail those 
infected and dividing by the total number sampled in a given 
area, for example in Kafr El Sheikh, would be incorrectly 
weighted. lo adjust for this, a procedure was formulated 
using a series of MIDAS commands. An estimated number 

infected was calculated for each age-sex group for each site 

in a given area of study. The age-sex specific prevalence 

at each site was used to make these estimates. The 

estimated numters infected in each age group for each site 
were added together and divided by the sum total of the 
population of all villages studied in the area. This result 
was the adjusted age-specific prevalence. The sum of all 
these estimated to be infected divided by the total 
population from all sites equalled the over all adjusted 
prevalence for a given area. Sex-specific adjusted 
prevalences were calculated using the same procedure, but 
selecting only male or female cases. 


99 


CHAPTER IV 


RESULTS 


The results have been divided into two major 
subheadings. Under the first subheading is the results of 
the study conducted in the rural downstream villages in the 
governorates of Aswan, Beni Suef, and Kafr El Sheikh. Under 
the second subheading is the results of the study conducted 
in the resettled Nubian villages of Kom Ombo. 


S^sults of the Dow nstream Stud y 


Selection of the Sample and Response 


The study sites or villages where survey data were 
collected were given the code number assigned to the health 
unit or center which serviced the village or villages 
sampled. Summarized in Table 27 are the code numbers for 
each village or site and the name of the corresponding 
health unit or center and by site the .number of persons 
examined, the number of families examined, the number of 
persons not giving a urine specimen, the number of persons 
selected but not attending (the so-called non-respondents), 
the number of houses examined, and the population at each 
sampled site. The probability of being selected from the 
total population sampled was 0.181. The population of all 
villages sampled in the Downstream Study sites totaled 
66,768 persons. The total number of persons sampled was 
12,059. The probability of being selected was not constant 
from site tc site, ranging from 0.08 to 0.58. Because the 
selection probability varied, grouped estimates of all sites 
for a given area required the appropriate weighting based on 
the sampling fractions. Of those selected, 93.2% attended. 
Of the persons who attended the examination, 6.0% did not 
give a specimen. (11,555 specimens in all were examined.) 
The variation in response between study sites was quite 
marked, particularly in the villages sampled by health units 
numbered 4 and 11. If these two sites are excluded the 
response rate is increased to 96.7%. There were 3020 houses 
for which data were obtained, although only 2894 families 
attended the examination. Apparently, there were 126 
families who allowed their homes to be examined and had 


100 







intended to come to the examination but were unable to do 

so. In many of the village sites everyone selected 
participated. The very good response obtained in this study 

is a remarkable testimony of cooperation by these village 
people. 


Age-Sex Distribution of the Sample 


The number of persons by area selected and attending 
the examination at the health units or centers is shown in 
Table 28 by 5 year age groups, except for the first age 
group which shows the number of infants less than one year 
of age, and the last age group which combines all those 
persons 65 years or older. Tables 29 through 31, show the 
number of persons by age, sex, and study site and their 
respective distributions. Generally there was little marked 
difference between the proportional size in like age groups 
within given area studied, i.e., for a given area the age- 
sex structure was very similar from site to site. Figures 
15 through 17 show the distribution of the age structures 
between sites for each area studied and graphically 
demonstrate these similarities. However, the chi square 
test indicated that the differences in age structure between 
sites in all three areas were statistically significant 
(p<0.01) indicating that adjustment for age structure is 
necessary when estimating various parameters within a given 
area or between areas. Sex ratios were not statistically 
significant between sites, but were significant between the 
three different study areas (chi square, p<0.01). 

Figures 18 through 20 were prepared to show the 
relationship between the sample age structure and the age 
structure based on the 1960 (CAPHAS, 1960) census for each 
of the respective rural areas. The resemblances between the 
age curves of the sample to the census age structure show 
that as far as population structure is concerned the study 
sites are representative of the areas from which they were 
selected. 


Overall Prevalence of Schistosomiasis in the Study Areas 

Kafr El Sheikh 


The number of persons in the sample from all village 
sites in the Kafr El Sheikh area positive for haematobium 
was 1,257 or 28.5^ of the sample, and for S^ 
persons or 19.655. There were 336 persons (7.7%) who were 

for cva in the stool or urine for both species and 
1,782 persons (40.3X) infected with either 




Table 27 

The Pattern of Selection and Response 
in the Downstreaia Study Sites, 




c: 




o 




•H 




X’ 




fO 




rH 




CJ 




a. 




o 




a* 




w 

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0) 

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o 

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a 

33 

& 


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tT» 


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OrO:a'CNO>OOOCNa>OOOOavr-' 

fN(Nr-'{Nt~»-'rNj(Nr-(N<N<N<NfM(N 


vDcr>rsj'^octooooopnLna>o 
cj- 00 ct vO CD 

(N (N 


LO'0)voc7>NOoc7>oor^ooLn-:tcNLn 
fNcrcJ-rsinofNCM’^cJ-CN t— r-OOcdh 


^ =T zt 
CT> rg CN 

r- (N 


O PO CO 
r- C7' O 

fvj T- r- 


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O ^ <T» 

(N CN T- 


00 C7> r— 

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r- r^3 rg 


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uo no 


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00 cjv r- 


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O- r- 00 

cr> cr^ 


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T— r-r-r-T— T— T— r-r— t—CN 



41 





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102 


Total 12059 2394 722 874 3020 66768 












20 . 




AGE CYEARSD 


Figure 15. The age distribution by study site in the Kafr El 
Sheikh study area. Each line represents a study site. The zero 
on the abcissa represents infants less than one year old. The 
next point represents the age group 1 to 4; the next, 5 to 9, 

10 to 14, and continues in five-year age groups. 


103 




Table 28 

The Number of Persons Attending the Downstream 

Study by Age and Area. 


Study Area 


Age — 

Group 

Kafr El Sheikh 

Beni Suef 

Aswan 

0<1 

66 

103 

42 

1-4 

518 

442 

206 

10-14 

724 

510 

550 

15-19 

521 

3 65 

385 

20-24 

284 

211 

245 

25-29 

344 

215 

211 

30-34 

214 

207 

184 

35-39 

294 

214 

227 

40-44 

237 

207 

225 

45-49 

275 

144 

179 

50-54 

146 

178 

197 

55-59 

140 

87 

96 

60-64 

115 

114 

109 

65 

88 

111 

91 

Total 

4651 

3677. 

3731 


haematobium or S. jansoni or both. Those infected with 
either one cr both species of schistosome comprise the group 
of infected termed ”schistosomiasis”. The overall 
uncorrected prevalence of schistoscmiasis in the Nile Delta 
study area is 40.3%. These figures are given in Table 32. 
The percent positive in the sample from all sites for this 
area does not correspond to an estimate of prevalence for 
all sites because of differences in population structure 
between the study villages and because of the variation in 
the probability of selection between sites. Adjustments for 
both age and sampling fraction were made according to the 
techniques described in Materials and Methods. Briefly, the 
appropriate weights were given to each age group according 
to the age structure and sampling probability for a given 
parameter measured by the study and then added across age 
groups for each site. 

The adjusted estimates of prevalence for the Kafr El 
Sheikh area and the standard error (a measure of sampling 
precision) are also given in Table 32. The estimate of 
prevalence and standard error for ll^§Mf 2 bium, 
Sjt USSoni, for infections with both species and for 
infections with either or both species by each study site is 
shown in Table 33. Sj, ma nsorii was lower in prevalence than 

104 






















Table 29 


The Number of Persons Examined in 

Kafr El Sheikh by Age and Site. 

Age 

Group 


Study 

Site Code 

Number 


16 

17 

18 

19 

20 

0<1 

6 

8 

'8 

15 

29 

1-4 

77 

102 

101 

98 

140 

5-9 

128 

154 

115 

115 

173 

10-14 

117 

166 

156 

130 

155 

15-19 

128 

117 

97 

88 

91 

20-24 

90 

43 

59 

52 

40 

25-29 

76 

60 

71 

63 

74 

30-34 

35 

59 

34 

30 

56 

35-39 

68 

46 

60 

35 

85 

40-44 

42 

57 

48 

45 

45 

45-49 

69 

41 

53 

59 

53 

50-54 

23 

39 

30 

31 

23 

55-59 

29 

29 

28 

31 

23 

60-64 

12 

39 

19 

22 

23 

65 ♦ 

16 

24 

17 

23 

8 

Total 

916 

984 

896 

837 

1018 


h aematobiu ii at all study sites except 19. There was a 
very high ccrrelation (r=0.967) between the prevalence of 
the two species by site indicating that if the prevalence of 
one organism was high the other would also be elevated. It 
follows that, if the conditions for transmission for one of 
the species was good it is probable that transmission for 
the other was also good for a given area. The prevalence of 
schistosomiasis was quite varied from site to site and 
statistically significant (chi square, p<0.01), being more 
than twice as high in El Aarzine (16) as in ttahalet Mousa 
(19). The differences in prevalence between sites were more 
marked for ^ hae ma tobium than for m ans oni. 


It should be borne in mi 
figures and the ones to follow 
examination of urine or stool, 
showed that successive examinati 
found positive, and Weir, ^ alj. 
indicated that the technique, exam 
characteristic schistosome ova, 
respect to false negatives, 
concerning the quantitative rela 

levels of prevalence and false 

105 


nd that these prevalence 
are based on a single 
Farooq and Nielsen (1966) 
ons increased the number 
(1952) using rectal snips 
ination of the excreta for 
was very insensitive in 
Data are not available 
tionship between different 
negatives. It suffices to 
























Table 30 

The Number of Persons Examined in 
the Beni Suef Study Area by Age and by Study Site. 




Study Site Code Number 


Age ” 

Group 

11 

12 

13 

14 

15 

0<1 

9 

29 

26 

26 

13 

1-4 

55 

21 

99 

9 1 

76 

5-9 

47 

133 

153 

130 

106 

10- 

59 

123 

145 

85 

98 

15-19 

43 

61 

108 

63 

90 

20-24 

23 

54 

47 

30 

57 

25-29 

24 

50 

57 

46 

38 

30-34 

18 

57 

44 

48 

40 

35-39 

23 

48 

57 

45 

41 

40-44 

26 

43 

46 

32 

60 

45-49 

16 

27 

38 

30 

33 

50-54 

14 

31 

31 

41 

61 

55-59 

7 

21 

22 

25 

12 

60-64 

13 

19 

20 

27 

35 

65 + 

7 

29 

27 

32 

16 

Total 

384 

846 

920 

751 

776 


say that meaningful comparisons can be made only when 
methodologies are similar. No attempt was made during this 
study to determine the proportion of cases remaining 
negative after successive examinations. Therefore, to most 
accurately show relative changes in prevalence, comparisons 
require that the separate data sets are not adjusted for 
false negatives. It would be invalid to evaluate changes in 
prevalence figures between different studies which had used 
different methods for detection and estimation. So long as 
the same sampling, examination, and estimation techniques 
ate adhered to, meaningful comparisons can be made. 


Deni Suef 


In the five study sites in the Beni Suef governorate, 
3391 specimens were examined for schistosome ova. The 
number of persons positive in this sample was 951. 
Prevalence between study sites varied significantly (chi 
square, p<0.01) with a high of 37.3% positive in Naiim (13), 
and a low of 16.9% in Shrief Pasha (12). Standard errors 

were calculated for the prevalence of schistosomiasis at 

106 


















Table 31 

The Nunber of Persons Examined in the Aswan 

Area by Age and by Site 


Aqe 


Study 

Site 

Code 

Number 


^ ^ 

Group 

1 



3 


4 

10 

0<1 

27 

11 


2 


0 

2 

1-4 

104 

92 


80 


84 

46 

5-9 

158 

118 


76 


143 

90 

10-14 

133 

150 


60 


137 

70 

15-19 

93 

125 


52 


58 

56 

20-24 

40 

92 


47 


29 

37 

25-29 

50 

62 


27 


41 

31 

30-34 

52 

37 


30 


28 

37 

35-39 

54 

68 


23 


47 

35 

40-44 

59 

57 


22 


51 

36 

45-49 

42 

51 


22 


46 

18 

50-54 

43 

50 


30 


44 

30 

55-59 

22 

24 


14 


16 

20 

60-64 

19 

30 


14 


36 

70 

65 ♦ 

12 

26 


9 


35 

9 

Total 

908 

993 


508 


785 

537 

each site and 

are 

shown in 

Table 

34. 

Because the age 

structure and sample 

fraction 

differed 

from site 

to site. 

the overall prevalence for all 

sites 

in 

the Beni 

Suef area 

was adjusted in 

the 

same fashion 

as 

described for Kafr El 

Sheikh. The overall 

adjusted 

prevalence for schistosomiasis 

was 26.7%. The 

adjusted prevalence was 

a few points less 

than the unadjusted 

crude 

prevalence 

of 28. 

1%. The 

prevalence of 

schistosomiasis 

in 

the 

Kafr El Sheikh study 

sites was more 

than one and a 

half 

times 

higher, even after 


adjusting for differences in age-sex structures between the 
two populations, than that of the Beni Suef study sites--and 
this is highly significant. Although the differences were 
not as great, the adjusted prevalence for haematobiu m 
alone in the Kafr El Sheikh sites was also higher than in 
Beni Suef and significant (chi square, p<0.001). There were 
20 persons in the sample positive for ^ MMoai ova, less 
than one percent of the sample. It is not known whether or 
not these persons had made previous visits in the Nile 
Delta. It should be noted that 63% of these cases were 
clustered in one village (Barout), and one case was detected 
in a one year old infant. 


107 
























PERCENT OF SAMPLE 


20 . 



Figure 16. 
study area. 


The age distribution by study site in the Beni Suef 
Each line represents a study site. 


108 







Table 32 

The Overall Prevalence of Schistosomiasis 
in the Kafr El Sheikh Study Area. 


Type of 

Infection 

Number of 
Specimens 
Examined 

Number of 
Specimens 
Positive 

Percent 
Positive 

Percent 

Positive 

Adjusted* 

Sj: haematobium 

4404 

1257 

28.5 

30.04t0.78 

£_. mansoni 

4402 

861 

19.6 

20.0±0.32 

Both Species 

4386 

336 

7.7 

8.0+0.20 

Either One or Both 

4421 

17 82 

40.3 

42.1±0.39 


♦Adjusted for sampling fraction and age structure 
betneen study sites. The figures following the plus and 
minus sign are the standard errors. 


Aswan 


In the five selected sites within the Aswan 
governorate, 3728 specimens were examined for schistosome 
ova; 180 were positive for S^ haema to bium or 4.8% of the 
sample. Variation in prevalence of schistosomiasis between 
sites was significant (chi sguare, p<0.01), with a low of 
0*2^ in Guzaiera (2); and highest in Eimban (10), which was 
7.8%. Standard errors and adjustments for age structure and 
sampling fraction were calculated using the same methods as 
described in the two other study areas. Table 35 shows 
these results. 

In Bimban (10), a subsample of 40 families was 
selected and examined. This subsample was initiated because 
of observed deficiencies in the laboratory personnel. This 
was the only site where incorrect procedure was observed. 
Bimban (10), by virtue of its location on the west bank of 
the Nile Biver, is considerably more isolated than villages 
located on the east side of the river. Villages on the east 
bank can be easily accessed by the Aswan-Cairo Motorway (see 
map. Figure 11). To reach Bimban (10), the Nile River must 
first be crossed in the Nile sailing vessel, the ”Falucca”, 
which is the only available means in this locale. The 
Bimban (10) Health Center is another 4.5 kilometers from the 
docking area on the west bank, and is reached either by foot 
or by donkey. The health center*s ambulance, the only 























PERCENT OF SAMPLE 



Figure 17. The age distribution by study site in the Aswan study 
area. Each line represents a study site. 


no 






Taole 33 


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Table 34 


Prevalence 

Study 

of S. 
Sites 

haematobium in 
, Upper-Middle 

the Beni Suef 

Egypt. 


Study 

Site 

Name 

Study 

Site 

Code 

Number 

Examined 

S. haematobium 
% Positive 

Barout 

11 

325 

27. 5 

Shrief Pasha 

12 

710 

16.9 

Naiim 

13 

857 

37. 3 

Beni Adi 

14 

708 

29.4 

Ashmant 

15 

758 

27.4 



3418 

26.7±0.25* 


♦ Adjusted for sampling fraction and age structure. 
Standard error follows the plus and minus sign. 


motorized vehicle in the village, was under repair 
throughout the period of the survey. The personnel staffed 
at the Biaban (10) Health Center invariably resided either 
in Daraw or in Kom Ombo on the east side of the river and 
commuted daily. Because of these and other undesirable 
working conditions, absenteeism was high, and there was a 
continuous turnover in the staff of the health center. It 
suffices to say that communication and administrative 
control were hampered. A number of approaches were 
suggested to help improve the collection of data at Bimban 
(10). One likely alternative way was to permanently house 
the necessary staff in facilities available at the health 
center. This suggestion was not 
Director-General of Health, who 
becomes comfortable in the bath, it may be undesirable to 
leave”. Although the rationale behind this analogy was not 
clear^ it was not pursued. Since there had also been 
numerous coiplaints by the staff about cooperation of the 
selected villagers, it was decided that a subsample would be 
drawn of 40 families or about 100 or more individuals, and 
that the physician at the health center would carry out all 
laboratory examinations of the urine specimens. The 
subsample was drawn by selecting every 5th family from the 
original selected sample of families. The subsample, 
therefore, was not independently selected. Therefore, those 

selected in the subsample were examined twice. It is 

112 


approved by 
feared that. 


the Aswan 
”once one 















AGE CYEARSD 


Figure 18. The adjusted age distribution from the Kafr El Sheikh 
study area and compared to the age distribution for this same rural 
area according to the 1960 census data (CAPMAS, 1960). Tlie solid 
line represents the data from CAPMAS (1960), the dashed line, from 
the sample. 


113 






Table 35 


Overall Prevalence 
the Study Sites of 

of 

the 

haematobium in 

Aswan Covernorate. 


Study 

Study 




Adjusted 

Site 

Site 

Number 

Percent Postive 

Overall 

Name 

Code 

Examined 

SjL 

haematobium 

Prevalence* 

Kazan Sharg 

1 

984 


6.9±0.9 

4.1±0.2 

Guzaira 

2 

947 


0.2±0.1 


Abu Rish 

3 

474 


4.2±0.9 


Ga’afra 

4 

760 


5.9±0.9 


Bimban 

10 

663 


7.8±0.4 


Totals 


3728 


4.8±0.4 



♦ Calculated on study sites 1 to 4 only. The 
figures following the plus and minus sign age the 
standard errors. 


unlikely that new infections were acquired by individuals in 
the subsaraple in the time period between their first and 
second examinations but this possibility must be borne in 
mind. It is especially unlikely in light of the large 
increase in the number of positives detected on re¬ 
examination, and this confirms the observation that correct 
laboratory techniques had not been adhered to. Thirty- 
seven, or 24.8% of the subsample were found positive for 
schistosomiasis. These findings are given in Table 36. 
Prevalence was found to be over six times higher than the 
adjusted prevalence for the other four study sites combined 
in the Aswan study area, which was 4.1%. 

In the overall sample from all areas and sites, more 
persons were infected with schistosomiasis in the Nile Delta 
than in any given study site or sites south of the delta in 
Beni Suef or in Aswan. In turn, the overall adjusted 
estimate of the prevalence was much higher in Beni Suef than 
in any of the study sites sampled in Aswan. 


Age-Sex Distribution of Schistosomiasis in the Study Areas 


114 













Table 36 

Besults of the Subsampie in Biraban^ Aswan. 


Parameter Result 


Number selected *149 

Number examined 149 

Number positive 37 

for S_. haemat obiu m 

Percent Positive 24.8±3.5% 

Sampling Fraction 0.04584 


Kafr El Sheikh 


Tabulation of the number examined and the percent 
positive in the entire sample from this area, for both 
species^ and for either one or both infections by 5 year age 
groups and by sex are given in Table 37. This analysis 
shows that the age group with the highest proportion of the 
sample infected with schistosomiasis, i.e., either one or 
both infections, was in the 15-19 year olds. This was true 
for both sexes with the males bearing a significantly higher 
proportion of the infection. Figure 21 shows the age-sex 
prevalence distribution of schistosomiasis for ail sites 
after adjusting for sample fraction and differences in age 
structure between sites. 

The age distribution of ^ haematobium infection in 
the sample and for the adjusted figures was significant (chi 
sguare, p<0.01) showing a rapid increase in the early years, 
peaking in the adolescent years and dropping by adulthood, 
in the early 20»£. This is a typical feature of 
schistosomiasis infections and can be seen in Figures 21 to 
24 which show the adjusted distributions by age and sex for 
schistosomiasis, haemato biu m^ ma nson i, and infection 
with both species, respectively. The distribution of 
prevalence by age for mansoni (Figure 23) was not as 
marked as for haemat obiu m and has an atypical rise in 
prevalence in the older age groups. This was more evident 
in the males than in the females. Farooq, et al^ (1966) 
comments on the differences in the age distributions between 
S, haematobium and mansoni and notes that S. mansoni does 

not fail~ as sharply in the adult age groups as does 

11 5 





























AGE CYEARSD 


Figure 19. The adjusted age distribution from the Beni Suef study 
area compared to census data for this area (CAPMAS, 1960). The solid 
line is the data from CAPMA.S (1960), the dashed line, from the sample. 


116 












Figure 20. The adjusted age distribution from the Aswan study area 
compared to census data this same region (CAPMAS, 1960). The solid 
line is the data from CAPMAS (1960), the dashed line, from the 
sample. 


117 






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118 


*Those witiiout age information were not included 


















®• Si ffl dnso ai seems to be acquired slower and 
to persist longer than ha ema tobium infections. The wide 
spread between the age prevalence of schistosomiasis and 
those infected with both species (see Figure 25) does 
suggest separate transmission sites and supports this view. 


Beni Suef 


The number of persons positive for haematobium in 
the Beni Suef area by five year age groups and by sex is 
shown in Table 38. As in the Kafr El Sheikh sites the 15-19 
age group had proportionately the highest prevalence. The 
number of females infected was less than the males for every 
age group. Age and sex distributions were significant (chi 
square, p<0.01) for both adjusted and un-adjusted figures in 
the Beni Suef area. Proportionately fewer females were 
infected in Beni Suef than in the Kafr El Sheikh sample. 
The prevalence was 2.08 times greater in the males in the 
Beni Suef sites than in the females, whereas the prevalence 
was only 1.4 times higher in males in Kafr El Sheikh. 
Figure 26 shows the age-sex prevalence (after adjustment) 
for S. haematobium in Beni Suef. 


Aswan 


The age-sex adjusted prevalence 
S ^ haematobium have been prepared in the same 
the results from Kafr El Sheikh and Beni Suef 
in Table 39 and Figure 27. Bimban (10) was 


curves for 
manner as for 
and are shown 
not included 


with these results, but was treated separately because it 
was not a desert type village. Results of the age-sex 
prevalence tabulations for the sample and the subsample from 
Bimban are given in Table 40. Bimban (10) was originally 
selected as a site that was not typical of this region, but 
rather isolated and located in an area more similar to the 
condition of other villages located in a fiat irrigated 
plain. The elevated prevalence of schistosomiasis in the 
subsample from this study site indicates that the conditions 
for transmission were strikingly different from those at the 
other four study sites, all of which had uniformly low 
prevalence. 


Schistosomiasis prevalence was highest (13.3%) in the 
age group 10 to 14 years old for these study sites numbered 
1 to 4 grouped together. This is one age group younger than 
the age group of highest prevalence in the two northern 
areas of Kafr El Sheikh and Beni Suef. Prevalence in the 
males was over 4 times higher than in the females. In 
Bimban (10), the age prevalence was slightly erratic, with a 
hiqh variance most likely due to the small size of the 

119 








Table 38 

Age-Sex Distribution of haematobiuia 
Infection in the Sample from the Beni Suef Area. 


II 1 1 1 nil N 


Infected 

with S. haematobium 

Age 

Group 

Males 


Females 

Total 

# Examined % 

# 

Examined % 

# Examined % 


0<^ 

20 

0.0 

21 

0.0 

41 

0.0 

1- 

4 

158 

5.1 

137 

5. 1 

295 

5. 1 

5- 

9 

312 

30.8 

249 

14.5 

561 

23. 7 

10- 

14 

265 

59.7 

237 

38.8 

502 

49.6 

15- 

19 

200 

69.0 

155 

37.0 

355 

55.2 

20- 

24 

71 

50.7 

121 

22.3 

192 

32.8 

25- 

29 

96 

38.5 

113 

10.6 

209 

23.4 

30- 

34 

85 

32.4 

120 

14.2 

205 

22.0 

35- 

39 

102 

39.2 

108 

11.1 

210 

24. 8 

40- 

44 

92 

38.0 

108 

8.3 

200 

22. 0 

45- 

49 

68 

19. 1 

75 

9.3 

143 

14.0 

50- 

54 

77 

23.4 

97 

14.4 

17 4 

18. 4 

55- 

59 

50 

32.0 

34 

8.8 

84 

22.6 

60- 

64 

61 

29.5 

53 

11.3 

114 

21. 1 

65 

•f 

69 

14.5 

39 

5. 1 

108 

11.1 

Totals 

1726 

37.7 

1667 

18. 1 

3393 

28.1 


population in the suhsample. Males had more schistosomiasis 
than females^ but the ratio was similar to that in the study 
sites of Beni Suef: 2.6, 


Environmental Aspects of the Downstream Study Sites 


Kafr El Sheikh 


In the past the villages in Kafr El Sheikh governorate 
had obtained their domestic water supply from the nearby 
canals and drains, or, where available, from public 
standpipes supplied by deep wells. (A standpipe is defined 
as a public water outlet of one or more taps attached to a 
vertical water pipe that may or may not have additional 
support, but typically are attached to a vertical concrete 
slab.) Since 1958, the standpipes have been supplied by a 
water treatment plant at Fowa. This is a typical tertiary 
water treatment plant; however, pressure in the distribution 

120 


















Table 39 

The Numbec Examined and the Percent Positive 
by Age and Sex for S_. hae mato bium 
in the Aswan Study Area Excluding the 
Results from Bimhan (10). 


Infected 

with haematobian 

Age Males 


Females Total 

\J JL vJ U ^ .... 

I Exasined % 

« 

Examined % # Examined % 


0<^ 

13 

0.0 

17 

0.0 

30 

0.0 

1-4 

156 

0.0 

170 

2.9 

325 

1.5 

5-9 

235 

7.7 

245 

2.0 

480 

4. 8 

10-14 

255 

20.8 

218 

5.0 

473 

13.5 

15-19 

156 

12.2 

162 

1.9 

318 

6.9 

20-24 

78 

5. 1 

123 

0.0 

201 

2.0 

25-29 

55 

1.8 

116 

0.9 

171 

1.2 

30-34 

47 

2. 1 

93 

1.1 

140 

1.4 

35-39 

61 

0.0 

123 

0.8 

184 

0.5 

40-44 

78 

1.3 

101 

1.0 

129 

1. 1 

45-49 

68 

1. 5 

82 

0.0 

150 

0.7 

50-54 

75 

1.3 

8.3 

0.0 

158 

0.6 

55-59 

45 

0.0 

28 

0.0 

73 

0.0 

60-64 

46 

0.0 

38 

0.0 

84 

0.0 

65 ^ 

43 

0.0 

38 

0.0 

81 

0.0 

NS* 

12 

8.3 

5 

0.0 

17 

5. 9 

Total 

1423 

1 1 

• 

o 

1 

1642 

1.7 

3065 

4.2 


* Not Stated. 


system is not always continuous, due to demand. The number 
of standpipes by study site, the number of persons per 
standpipe, and the prevalence of schistosomiasis by study 
site is shown in Table 41. There seems to be no obvious 
relationship between schistosomiasis prevalence and the 
number of persons per standpipe, which ranges from 540 to 
2C7 Table 42 shows the number of persons in the sample by 
source of water and by the type of use. Since the use of 
different water sources is not exclusive, the numbers show a 
measure of preference by the persons in the sample. It is 
evident that outside pipes (standpipes) were the most 
coimonly used source of drinking water, but the other water 
5°e activities, such as bathing, were frequently divided 
between the protected sources and the canals or drains. 

An analysis to determine 


the relationship between 




















80 . 




H-1-1-1-1-1- 

10 . 20 . 30 . 40 . 50 . 60 . + 


AGE CYEARS] 


Figure 21. The adjusted age-sex prevalence distribution for 
schistosomiasis for all study sites combined in the Kafr El Sheikh 
study area. The long dash corresponds to males, the short dash to 
females, and the solid line for the total. 


122 




Table 40 

The Number Examined and the Percent Positive by Age and Sex 
for Sj. haeraatoWum in the Bimban (10) Sufcsample. 



Infected 

with ^ 

. haematobium 


Age 

Group — 

Males 


Females 

Total 


# 

Examined 

1 

Examined % 

# Examined 

% 

0<1 

0 

0 

1 

0 

1 

0. 0 

1-4 

2 

0 

5 

0 

7 

0.0 

5-9 

7 

86 

11 

33 

18 

55.6 

10-14 

12 

50 

12 

11 

24 

29.2 

15-19 

12 

33 

10 

10 

22 

31.8 

20-24 

10 

60 

3 

33 

13 

53. 8 

25-29 

5 

20 

3 

0 

8 

12.5 

30-34 

3 

100 

8 

20 

11 

36, 4 

35-39 

1 

0 

6 

17 

7 

14.3 

b0-4a 

7 

0 

6 

0 

13 

0. 0 

45-49 

2 

0 

2 

0 

4 

0.0 

50-54 

4 

0 

4 

0 

8 

0.0 

55-59 

3 

0 

1 

0 

4 

0.0 

60-64 

2 

0 

3 

0 

5 

0.0 

65 ♦ 

3 

0 

1 

0 

4 

0.0 

Total 

73 

36 

76 

14 

149 

24 . 8 


schistosome infection and the source of water did not show 
any distinctive patterns until all those who had scored the 
data forms for more than one source were eliminated in the 
piped inside and piped outside categories^ the rationale 
being that if an individual obtained water from an 
unprotected source as well as a protected one it would 
confound the impact on the evaluation of the protected 
supplies. The results shown in Table 43 by source and use 
of water are combined data for 
Sheikh. These persons fortunate 
into their homes and who did not 
sources from outside the home 
those who obtained their drinking water solely from 
standpipes. The latter group, in turn, had a lower 
prevalence than those who used the canals as a source. This 
observation was consistent regardless of what the water was 
used for and showed an even greater differential for 
S_. m anson i infections, which is given in Table 44. 

In the Kafr El Sheikh study, 90% of the sample had 
latrines. prevalence of either species was not 
significantly different between those having a latrine or 


all study sites in Kafr El 
enough to have water piped 
supplement this supply with 
had lower prevalence than 



























Table 41 

The Prevalence of Schistosomiasis and the 
Distribution of Persons per Standpipe in the 



Kafr El 

Sheikh study 

area. 


Study 

Site 

Code 

# Standpipes 

Persons per 
Stand pipe 

Schistosomiasis 

Percent 

Prevalence 

16 

20 

207 

66.5 

17 

7 

420 

45.9 

18 

4 

508 

31.2 

19 

5 

540 

21.5 

20 

28 

262 

28.7 


Table 42 

The Number of Persons in the Sample 
from Kafr El Sheikh 
by Hater Source and Use, 


Hater Use 


water source 

Drinking 

Bathin g 

Laundry 

Utensils 

Animals 

Piped inside 

197 

193 

105 

85 

29 

Piped outside 

4183 

3631 

2909 

2878 

121 

Hand pump inside 

12 

57 

57 

57 

2 

Hand pump outside 

8 

10 

10 

2 

0 

Canal 

909 

3091 

2993 

2927 

2822 


not having one. 


124 

























Figure 22. The adjusted age-sex prevalence distribution for S. 
haematobium infections for all study sites in the Kafr El Sherkh 

study area. The long dash corresponds to males, the short to 
females, and the solid line for tne total. 


125 





Table 43 

The Percent Prevalence of haematobium by Source and Use 
of Water Supply from Kafr El Sheikh study area. 


Water 

Source 



Water Use 


Drinking 

Bathing 

Laundry 

Utensils Animals 

Piped 

inside 

13.3 

13.3 

13.3 

13.3 0.0 

Piped 

outside 

19.2 

20. 0 

18. 2 

18.0 16.7 

Canal 


33.3 

32.8 

34.6 

34.6 32.9 


Beni Suef 


Table 45 shows the distribution of standpipes in the 
study sites of Beni Suef. Again, no relationship seems 
evident between the number of persons using a standpipe and 
schistosomiasis prevalence. The number of persons in the 
sample and their respective sources of water by use is given 
in Table 46. Hand pumps, often seen installed near the 
canals, are a common source of water in this area. When 
water source data and prevalence of schistosomiasis were 
adjusted for multiscurce uses a distinctive pattern emerged, 
similar to that seen at the Kafr El Sheikh sites (see Table 
47). Prevalence of schistosomiasis decreased with 
iffproveroent in the quality of water source. 

Only 37.35? of the houses in the sample from the Beni 
Suef area had latrines. The persons residing in homes that 
had latrines had less schistosomiasis, 22.6%, than those who 
did not, 31.4%. 


Aswan 


There seems to be a consistent lack of relationship 
between the number of persons per standpipe and the 
prevalence of schistosomiasis. Data from the study sites in 
Aswan, and tabulations for the number of persons per 
standpipe (given in Table 48) are in accordance with this 
observation. In the study sample from sites 2, 3, and 4 
(Guzaria, Abu Bish, and Ga*afra, respectively) water sources 
for domestic use were obtained invariably from standpipes. 
Only small irrigation canals are found in the area where 

126 















AGE CYEARSD 


Figure 23. The adjusted age-sex prevalence distribution for 
mansoni infections for all study sites in the Kafr El Sheikh study 
area. The long dash corresponds to males, the short dash to females, 
and the soled line -for the total. 


127 






Table 44 

The Percent Prevalence of S_. fflansoni by Source and Use 
of Water Supply in the Sample from Kafr El Sheikh. 




Water Use 

n ^ ^ ^ vJ U J» 

Drinking 

Bathing Laundry Utensils Animals 


Piped 

inside 

6.7 

6.7 

6.7 

6.7 

ND^ 

Piped 

outside 

12.3 

12.8 

11.9 

11.7 

ND 

Canal 


24.7 

21.4 

22. 1 

22.0 

21.2 


♦ No Data 


The Prevalence 
Persons per 


Table 45 

of Schistosomiasis and the Distribution 
Standpipe in the Beni Suef Study Area. 


of 


Study 

Site 

Code 

Number of 
Standpipes 

Persons per 
Standpipe 

Percent 

Prevalence 

11 

0 

0 

27.5 

12 

6 

827 

16. 9 

13 

8 

201 

37. 3 

14 

7 

968 

29. 4 

15 

13 

712 

27.4 


these villages are located^ and are at inconvenient 
distances from the villages, thus precluding their use in 
favor of the standpipes. In Kazan Sharg (1), the Nile was 
the exclusive source of water. It should be mentioned that 
there are nc upstream populations from Kazan Sharg (1); the 
village is very near the outfall of the old Aswan Dam, where 
the water guality of the River Nile in Egypt is at its best. 
Approximately one month following the field work in Kazan 
Sharg (1) standpipes were installed throughout the village 
and supplied by the new Aswan water treatment plant. Water 





















Table 46 

The Number of Persons in the Sample from 
Beni Suef by Water Source and Use. 


Water Source 



Hater Use 


— 

Drinking 

Bathing 

Laundry 

Utensils 

A nimaIs 

Piped inside 

11 

9 

9 

9 

0 

Piped outside 

306 

301 

200 

181 

2 

Hand pump inside 

46 

42 

41 

40 

0 

Hand pump outside 

583 

561 

439 

435 

26 

Canal 

3 0 

65 

272 

242 

296 


Table 47 

The Percent Prevalence of haem atob ium 
by Source and Use of Water 
supply in the sample from Beni Suef. 


Water Use 



Drinking 

Bathing 

La undry 

Utensils 

Animals 

Piped inside 

10.5 

9.7 

15. 4 

9.7 

NC_ 

Piped outside 

21.4 

21.0 

19. 1 

19.3 

NC 

Hand pump inside 

27.7 

30.0 

30.9 

27.2 

NC 

Hand pump outside 

30.6 

31.0 

29.0 

28. 5 

NC 

Canal 

35.3 

35.2 

31.7 

31. 3 

32.3 


♦ No Cases. 


for standpipes in Guzaria (2) $ and in Abu Rish (3) , was also 
supplied by the treatment plants in Aswan. In Ga'afra^ the 
water for standpipes was supplied by the water treatment 
plant in Daraw (see map. Figure 11). In Bimban (10), 75.4% 
of the homes had indoor hand pumps and 21.5% of the sample 


































obtained their water from outdoor hand pumps# The remaining 
3#9X were scattered between the canals and the drains. In 
the subsample from Bimban (10), domestic water was uniformly 
obtained from hand pumps inside the house. 


The per 
in Table 49. 
had latrines 
developed are 
example. The 
the presence 
square, p<0.0 
4. These res 


centage of the sample with latrines are shown 
In the sample as a whole, 65.1% of the homes 
, an impressive figure for a rural under- 
a, of which the study sites at Aswan are a good 
relationship between schistosome infection and 
of a latrine was significantly lower (chi 
1) for those who had them in study sites 1 to 
ults are also shown in Table 49. 


Results of tt^ Resettled Nubian Study 


Selection of the Sample and Response 


As mentioned, the villages selected for study were the 
same villages surveyed by Zawahry (1964) before the Nubians 
were relocated. In addition, data were also collected from 
two other villages, Tuskha (6) and Kalabsha (9). Summarized 
in Table 50 is the descriptive pattern of selection and 
response by study site. Ail those selected and requested to 
attend did so. The combined population of all the Nubian 
sites examined was 16,065 and the total number of persons 
examined was 3,275. Probability of selection varied from 
site to site as it did throughout the Downstream Study and 
ranged from 0.10 to 0.69. There were 493 who did not give a 
urine specimen and 2,762 who did, or SS% of the total. 


Age-Sex Distribution of the Nubian Sample 


The age-sex distribution of the Nubian sample as a 
whole and by site is given in Table 51. Figure 28 shows the 
proportional age curves by site for comparative purposes. 
The age and sex structure between sites was statistically 
significant (chi square, p<0.01). Typically, Nubia has had 
more females than males as is the case in this sample, but 
past data (Zawahry, 1964) suggests that males are in 
proportionately greater number than before. 


Overall Prevalence of haematobium in the Nubian Sample 


The 

the sample. 


cumber of persons 
iuffl in their urine or 
After adjusting for 

130 


in the sample passing 
stool was 244, or 8.9% of 
the sampling fraction and 






80 . 



liJ 

U 

z 

UJ 

«J 

< 

> 

UJ 

a: 

Q- 


UJ 

u 

a: 

UJ 

0 . 


40 .-- 


20 .-* 



AGE CYEARS3 


Figure 24. The adjusted age-sex prevalence distribution for infections 
with both species for all study sites in the Kafr El Sheikh study 
area. The long dash corresponds to males, the short dash to females, 
and the solid line for the total. 


131 




Table 48 

The Number of Persons per 
Standpipe by Study Site in Aswan. 


Study 

Site 

Code 

Number of Population 
Standpipes 

Persons per 
Standpipe 

^Prevalence of 
S. haematobium 

1 

0 

2371 

0 

6. 9 

2 

8 

40 21 

503 

* 

O 

3 

3 

1915 

638 

4. 2 

4 

55 

4701 

85 

5. 9 

10 

0 

3076 

0 

22. 1 


age-sex differences fcetween the five study sites the over¬ 
all estimated prevalence was 7.2%. The prevalence of 

haemat obium at each site varies significantly (chi 
square^ p<0.01)y although generally low in the Nubian sample 
as a whole, except for Kalabsha (9). These results are 
shown in Table 52. The suprisingly high prevalence in 
Kalabsha (9) seems to be atypical of this region, and the 
higher prevalence in females than males is unique to all 
study sites throughout. This aspect is further assessed in 
the following section. Figure 29 shows the age adjusted 
prevalence in the Nubian sample for S_. hae matobiu m. These 
results do not exclude the possibility of sporadic 
S. manso ni infections in any of the Upper Egypt study sites. 

Environmental Aspects of New Nubia 


The villages of New Nubia, built in 1963 by the 
Egyptian government in a attempt to compensate these people 
for the loss of their homes, are typical of expedient low 
cost ”social” housing projects with each housing unit 
invariably constructed like the one before it. Therefore, 
environmental variation from village to village was minimal. 
All houses had been built with a latrine, and standpipes 
were present throughout the villages. Except for Kalabsha 
(9) and Daboud (not a study site), all the villages of new 
Nubia were located to the east of the Aswan-Cairo Motorway 
at the edge of the Kom Ombo agricultural plain in the 
desert, strategically located at a distance from the 
irrigation water courses. Treated water was supplied by a 

joint distribution system connected to both the water 

132 

















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133 










PERCENT PREVALENCE 


80 . 


60 . 



AGE CYEARSD 


Figure 25. The adjusted age prevalence distribution for those infected 
with both species (dash line) and for those infected with either 
or both species (solid line). 


134 





Taule 50 

The Pattern of Selection and 


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135 














80 . 



Figure 26. The adjusted age-sex prevalence distribution for S. 
haematobium infections in the study sites from the Beni Suef study 
area. The long dash corresponds to males, the short dash to females, 
and the solid line for the total. 


136 





Table 51 

The Number Examined and the Percent Positive 
by Age and Sex for haematobiug in the Nubian Sample 


Infected with S^ haejatobium 


Age 

Group 

Males 

Females 

Total 

# Examined % 

# Examined % 

# Examined % 



0<1 

14 

0.0 

6 

0.0 

20 

0.0 

1-4 

126 

1.6 

130 

1.5 

256 

1.6 

5-9 

164 

4.9 

186 

8. 1 

350 

6.6 

10-14 

179 

14.0 

159 

3.8 

338 

9.7 

15-19 

145 

18.6 

181 

9.4 

326 

13. 5 

20-24 

60 

31.7 

119 

10. 1 

179 

17,3 

25-29 

47 

21.3 

109 

13.8 

156 

16.0 

30-34 

44 

18.2 

97 

8.2 

141 

11.3 

35-39 

37 

16.2 

122 

5.7 

159 

8.2 

40-44 

8 

17.8 

98 

9.2 

143 

11.9 

45-49 

54 

7.4 

95 

8.4 

149 

8. 1 

50-54 

44 

9.1 

75 

8.0 

119 

8. 4 

55-59 

44 

11.4 

91 

4.4 

135 

6.7 

60-64 

42 

2.4 

54 

1.9 

96 

2. 1 

65 ♦ 

75 

1.3 

112 

4.5 

182 

3. 2 

Total 

1120 

11.4 

1634 

7.0 

2754 

8.9 


treatment plants in Daraw and in Kom Ombo. Villages at the 
extreie ecd of this distribution system suffered 
intermittent water supply due to excessive demand, 
especially in the hot dry summer months. El Nalki (7), 
Kurta (8), and Kalabsha (9) were all limited to a few hours 
a day when the water pressure in the system was sufficient 
to reach these villages. All villages in new Mubia have 
electricity, a benefit of the AHD. 


137 



























AGE CYEARS3 


Figure 27. The adjusted age-sex distribution for S. haematobium 
infections in the study sites from Aswan study area. The results 
from Bimban (10) are not included. The long dash corresponds to 
males, the short dash to females, and the solid line for the total. 


138 









20 . 



O.H-1-1-1-1-1-1- 

0 . 10 . 20 . 30 . 40 . 50 . 60 . + 

AGE CYEARSJ 


Figure 28. The age distribution by study site in the Nubian sample. 
Each line represents a study site. The abnormally high percentage 
of persons in the sixty and over age groups was found in Kurta (8), 
represented by the-, solid line. It reflects the excessive outward 
migration by younger groups. 


139 








Table 52 

The Percent Prevalence of haemato bi um 
in the Nubian Sample by Study Site 


Infection with S. haematobium 


Study 

Site 

N ame 

Study — 

Site 

Code 

Number 

Examined 

Percent 

Positive 

Ballana 

5 

535 

5. 8 

Tuskha 

6 

649 

3.7 

El Balki 

7 

597 

2.0 

Kur ta 

8 

461 

1.7 

Kalabsha 

9 

512 

32. 8 

Total 


2754 

8. 8 


140 














PERCENT PREVALENCE 


80 . 




20 .“ 



Figure 29. The adjusted age prevalence distribution for S. haematobium 
infections in the Nubian sample. 


141 





CHAPTER V 


DISCUSSION AND CONCLUSIONS 


Like the Results section, the discussion is presented 


under two major subheadings: the 
studies* 


downstream and the Nubian 


IliS Downstr ea m Sj^d^^ General As£ects 


A large scale 
in the rural areas 
ARE. Thirty-three 
typicality to repre 
Valley in Egypt: 
Upper Egypt. In 

population were se 
and examined for 

described. Prevale 
respective areas 
sampling fraction a 
the various study 
when comparisons ar 
or between the resu 
Data were also o 
environments of the 


country-wide field survey was completed 
of the Nile Valley downstream from the 
villages were chosen on the basis of 
sent the three major regions of the Nile 
the Nile Delta, Upper-Hiddle Egypt, and 
these village sites members of the 
lected according to known probabilities 
infection with schistosomiasis as 
nee figures for schistosomiasis in the 
have been adjusted for differences in 
nd age structure of the populations at 

(Only adjusted figures are used 
between the different study areas 
this research and other works.) 
on the housing and village 


sites. 

€ made 
Its of 
btained 


sampled population. 


The general aspects of the results of this survey show 
that the prevalence of schistosomiasis is highest in the 
rural villages sampled in the north central delta where both 
species of schistosome are present. Aside from the long 
term intensive perennial irrigation in the delta which no 
doubt has contributed to the high overall prevalence, the 
increased risk of acquiring either species is another reason 
that the prevalence of schistosomiasis is elevated. If all 
those who were infected with one species were invariably 
infected with the other there would be only an increase in 
morbidity rather than in prevalence. However, the results 
show that infection with either or both species of 
schistosome is over five times more prevalent than infection 
with both species. This large difference 
shows that transmission of the two species is 
great degree at separate sites. 


in prevalence 
occurring to a 


142 




Faroog (1966) has also observed that transmission of 
the two species depends on separate sites. Main drains and 
canals were found to play a more significant role in the 
transmission of i§^J§tobiuo, whereas distributaries, 
(smaller canals used to distribute the water to the field 
channels) were more important for mansoni transmission. 


The prevalence of both infections and of 

schistosomiasis varied dramatically from one site to 
another, reconfirming that schistosomiasis in Egypt is 
focally distributed. Scott (1937), Faroog, et aj,^ (1966), 
and others have also noted this aspect. This was also true 
for the study sites in Beni Suef and in Aswan. The 
interesting correlation between the prevalence of 

J-i tobium and manson i by site in Kafr El Sheikh in 

this study, suggesting that conditions good for the 
transmission of one species are favorable for the other, 
have not been observed before. It is not known whether this 
relationship is true in other sectors of the Nile Delta 
where prevalence of the two species is at an overall 
^iffgrent level or not. It is possible that if good 
conditions for S_. ma nsoni transmission exist then they are 
also favorable for haematobium. but not vice versa. It 

is significant that the prevalence of man soni 
was invariably lower than haematobium 

regardless of the study site picked. This is 
with findings of past surveys in the Nile Delta. 


infections 

infections 

consistent 


The age-sex distribution of haematobium was 

typically higher in males than females and highest in the 
younger age groups. manso ni infections did not follow as 

closely the typical age-related distribution, remaining high 
in the adults rather than dropping in prevalence like the 
SjL haematobium infections. A number of hypotheses have been 
formulated to explain the age-related differences for both 
species (Faroog, et ai^ 1966), but the lack of a higher 
prevalence in the adolescent years for lansoni reguires 
further explanation. Two possibilities are suggested. 
First, it is possible that the age distribution of 
S, mans oni seen in the study sites is being altered due to 
spontaneous changes in the ecology of the disease and its 
transmission. Evidence is now available to show that 
changes in prevalence have been occurring in this area over 
a rather long term as discussed in the Review of Literature. 
Second, locally implemented control programs are often 
directed at the groups with the highest prevalence, i.e., 
the youth. School health programs designed to detect and 
treat the enrollees for schistosomiasis are reguired by law 
and are carried out with varying degrees of efficiency. It 
is possible that these and other control measures have had 
seme success, thus depressing the peak of prevalence usually 
seen in these age groups. However, the age prevalence curve 
for S. haematobium was not depressed in the young age 

would” be expected if control measures were 

143 


groups, as 














working. Studies in Beheira by Farooq and Hairston (1966) 
showed that the incidence rates for haematobium were 

almost three times as high as those for ^ m ans oni. 
Although this explanation is the more unlikely of the two, 
it is possible that some of the h aemat obium infections 
were cured but quickly reacquired. 

South of the Nile Delta in the study sites selected in 
the Beni Suef area, the adjusted prevalence of 

haem atobium was a few points below that of the delta 
sites in Kafr El Sheikh, 26.7% as compared to 30,0%. The 
age-sex prevalence followed a typical distribution in these 
study sites. When only males are compared, the results from 
Beni Suef show, interestingly enough, that this area was 
higher in prevalence. The prevalence for males in Beni Suef 
is 37.0% and in Kafr El Sheikh cnly 35.2%. Obviously the 
prevalence of hae mato bium in females was much lower in 
Beni Suef. Indeed, the difference in the distribution of 
J* prevalence between the sexes is much greater 

in Beni Suef, almost twice that in the delta sites. In the 
villages studied in Aswan, the differences in prevalence 
between sexes were was again greater, by two times. This 
sex related differential seems to increase from north to 
south, as the prevalence of the disease decreases. This 
unique observation has a number of implications concerning 
control strategies. 

In the Aswan study sites, except for Bimban (10), 
prevalence of haem at obium was remarkably low. The 

overall adjusted prevalence was only 4.1%. As just pointed 
out, the difference in prevalence between the sexes was the 
greatest here of all the study areas, and there was 
significant variation of prevalence between study sites. 
The prevalence of J_. haem at obi um in Guzaiera (2) was the 
lowest recorded (0.2%) in any of the downstream villages 
studied. Many of the villagers from the Guzaiera (2) site 
were employed in occupations other than agriculture and many 
worked in the city of Aswan which is only a few kilometers 
away to the south. Equally important, and typical of other 
villages with low prevalence in this study area, Guzaiera 
(2) is located on high, dry, barren ground outside of the 
narrow strip of cultivated land that lies along the Nile. 
Continuing north from here, the Nile Valley is very narrow, 
widening gradually as it passes through the next two 

governorates, Qena and Sohag (see map. Figure 10). Only in 
the Kom Ombo plain does the valley widen to any extent. 
North of this plain the valley returns to the narrow 
confines typical of the region. Land available for 

cultivation is scarce throughout the Aswan governorate, 
except in Kcm Oubo, and the local villagers have wisely not 

built on land that could be used for growing crops. In the 

study sites located north of the city of Aswan and south of 
the Kom Ombo plain, the villagers live at a greater distance 
from the irrigation canals than do the villagers located in 










the delta or in Upper-Middie Egypt. In the delta or in 
Upper-Middle Egypt villages are built in and are surrounded 
by cropped land. in addition to being isolated from the 
irrigated land, many of the villages of the Aswan region are 

supplied with treated water, as was pointed out in the 
Results. 

are found within the cropped areas with 
increasing frequency as one travels north out of Aswan into 
the Qena and Sohag governorates. North of Sohag only a 
small fraction of the rural population resides in villages 
located outside the cultivated land, and these villages are 
often bounded on one side by their fields. For convenience, 
’’desert village” has been defined as one located on dry, 
unvegetated, barren ground; and a ”non-desert village” is a 
village in and surrounded by irrigated productive land. In 
order to have some measure of prevalence in an non-desert 
village, Biirban (10) , on the west bank of the Nile in the 
Kom Onbo plain, was surveyed. Sugarcane is cultivated here 
and thick stands of date palms are common. Hater for 
domestic purposes is either piped from a deep well, pumped 
by hand from shallow wells, or taken directly from the 
nearby canals. In this village 24.3K of a subsample were 
positive for haem a tobiu m. Although these results are 
based on a more limited sample than usual in this village 
area, it is a strong indication that schistosomiasis 
prevalence is considerably higher in the non-desert type of 
village. This new evidence suggests that prevalence between 
villages can vary greatly, certainly more than what has been 
seen in the northern areas of Beni Suef and Kafr El Sheikh. 
This is most likely true of Upper Egypt in general where 
both these types of villages are common. It is important 
that future prevalence surveys in Upper Egypt take into 
consideration the types of villages selected for study. 
Differences in water supply of selected villages (discussed 
below) and differences in location, whether in the desert or 
in the cultivated land, suggest very different rates of 
transmission. 

In light of this finding, past studies done in Upper 
Egypt now must be reexaamined in order to determine if the 
villages sampled were ’’desert type”, ”non-desert type”, or a 
combination of both. In turn, it is necessary to determine 
the exact distribution of the rural population between these 
two village types in Upper Egypt so that results from these 
areas can be appropriately weighted. Without this 
information, which unfortunately is not currently available, 
prevalence figures cannot be readily applied to the general 
area. Ideally^ samples in future surveys should be selected 
to be representative of the distribution of the total 
population among the various village types. 


145 



Supply and Schistos omia sis 


Egypt has had a progressive program for the 
installation of publicly accessible protected water supplies 
since the early 1950’s, Of all the villages sampled in 
either the downstream or Nubian study, only in Kazan Sharg 
(1) were protected sources of water totally absent. Now 
standpipes are present throughout the village, supplied by 
the new Aswan Water Treatment Plant, Barout (15) and Bimban 
(10) were the only other villages which did not have 
standpipes and depended heavily on water from shallow wells 
where hand pumps had been installed. 

When available, protected sources of water, either 
from standpipes or from hand pumps, were preferred for 
drinking over unprotected sources and were used heavily (see 
Tables 41, 45), However, these sources seemed to be 
inadequate for other uses in Upper-fliddle Egypt and in the 
Nile Delta where activities such as bathing, laundry, 
etc. were still frequently carried out in the canals. In 
particular, water use for animal care and cleaning, in most 
cases, involves exposure to highly contaminated sources. 
The Egyptian fe lahe en take pride in keeping their livestock 
clean, especially the domestic water buffalo, common 
throughout Egypt. Water buffalo require frequent dips. 
According to Farooq et al. (1966) this is not an activity 
dene solely by adult men but involves both sexes, including 
the younger age groups. It would seem that alternatives to 
the unprotected canals as water sources for animal care 
would be difficult to formulate. This must be kept in mind 
as a water-related behavior with a high potential for 
exposure to schistosome infection even when protected public 
supplies are readily available. 

It has been shown in this study and in others 
(Farooq,et al_. 1966a; Unrau, 1975) that protected water 
supplys strongly influence the prevalence of 
schistosomiasis. The prevalence of both species of 
schistosomes in the Nile Delta was shown to be related to 
the quality of the water source. A gradient of improvement 
in prevalence was seen as the quality of the water source 
improved. This was very dramatic in the sample sites of 
Opper-Middle Egypt where there were more possibilities for 
different sources of domestic water. In Upper Egypt 
protected sources were utilized even more intensively for 
most water-related activities. Infection in Upper Egypt 
(excluding Bimban (10)) with schistosomes, although much 
less than in the ether areas, is probably being acquired 
during the period when the domestic animals are being 
washed. In the region of the Aswan study sites, this 
activity invariably takes place in the Nile itself, and, 
like most large streams, the river is an inefficient site 
for transmission. 





of lansoni and the AH D 


Recent studies (Almy and Cline, 1977) have indicated 
that the distribution of is changing in the 
southern-most areas of the Nile Delta, and that this may be 
a result of controlling the Nile*s discharge by the AHD, 
Furthermore, there has been speculation that mansoni 
infections have already invaded areas south of the Nile 
Delta. The hypothesis is that the annual flood had 
restricted the Biomphalaria species to the calmer waters of 
the canals and drains of the lower Nile Delta, whereas the 
less delicate Bulinus group was able to establish itself 
throughout the country. While this is a widely held belief, 
there is no evidence to show that the ecology of 

is solely dependent on water discharge or 
velocity. The concern, however, is well founded in that the 
spread of mansoni infections to new areas is a serious 
threat if the prevalence patterns of the Nile Delta are any 
indication of what would happen if this snail species did 
indeed expand its territory. 

In Beni Suef, twenty persons were positive for 
SjL aans oni in their stool specimens, less than one percent 
of the sample. Whether or not this indicates that 
Sjl ®§RSoni has established a focus of infection south of the 
delta remains to be confirmed. The presence of the snail 
host, B iompbalari a. has not been investigated. Furthermore, 
it cannot be stated for certain that those infected have 
acquired the mansoni parasites in the Beni Suef area or 
in the north during trips to the delta. Thirteen persons 
were detected with S. infections in 1972 (Hussein, 
1972), in the same study sites. If these infections were 
acquired in Beni Suef then there is reason to believe that 
S. manso ni infections could be found thoughout Upper-Hiddle 
and Upper Egypt. Indeed, mansoni infections have been 
reported to be very prevalent (60%) south of Egypt in the 
Gezira irrigated area of the Sudan (Webbe, 1972) and are 
found consistently throughout the remaining southern 
pcrtions of the Nile river basin. From this prepective it 
would seem reasonalbe that ^ MBScni infections would have 
always been distributed along the entire length of the river 
valley. However, no one has yet explained the limited 
distribution of Sj^ man son i infection in the Nile Delta that 
has been seen in the past. Scott (1937) was intrigued by 
the sharp demarcation which divided the regions of the delta 
into areas of high and low infestation with S_. man soni. He 
could not find any noticeable change in the topography or in 
the systems of irrigation between these areas. Nor could a 
reason be found based on the type of crop grown in these 
respective regions. He concluded that there was some 
controlling human factor that would account for the sharp 
difference seen, although the areas in question seemed 
demographical ly homogeneous to^ each other. The point is 














that any Sj*. gansoni intections detected in areas south of 
the delta, can not be explained totally by changes in 
hydrology* A fuller understanding of the life cycle and 
biology of the parasite is necessary before conclusions can 
be drawn about how the construction of the AHD may be 
affecting the distribution and transmission of ^ 

However, the possibility of sporadic cases in Upper-Middle 
and Upper Egypt remains and must be investigated* 

General Estimates of Schistosomiasis 


It is very desirable to use the findings from the 
three different areas (four including Nubia) for which 
prevalence figures for schistosomiasis have been obtained to 
calculate estimates of prevalence for the general rural 
population* This must be carefully approached for several 
reasons* 

One, the technigue most commonly used in the past and 
employed in this study, i*e., the presence of characteristic 
ova in the excreta, is insensitive, with unknown numbers 
examined and classified as negative who are in fact 
positive* Neir, et al_* (1952) showed long ago that time- 
consuming and elaborate methods must be employed before an 
individual can be confirmed free of schistosoma infection. 
Any findings based on ova detection in the excreta have to 
be interpreted as underestimates* Furthermore, there has 
not been the necessary experimental work to show exactly how 
underestimated these prevalence figures would be. The 
findings of Weir et al^ (1952) suggested that as many as 
881^ of those negative for ova in the urine on one 
examination could be shown to be positive by examining 

rectal snips. Therefore, any survey using detection of ova 
ic the excreta as a method of prevalence determination 
cannot provide an exact number of all those infected* 
Nevertheless, results based on these methods continue to be 
presented, partly because of the practical ease with which 
data can be obtained and also because data based on ova 

detection are very useful for developing trends over time, 
demonstrating differences in relative intensity of infection 
from one location to another, and monitoring control 
programs* In addition, the usefulness of results based on 
ova detection in the excreta can be increased by 

(1) determining the number of ova in a given amount 
of excreta and thus providing a measure of 
intensity of infection in the individual, and 

by designing an ova detection survey to show 

incidence (i.e., the number of new infections 

occurring in a given period)* Incidence 
determination is the only direct method of 


(2) 










revealing changes in transmission. 


Two, 

geographic 
population 
population 
will have 
proportion 
the total. 


the total rural populations of the three 
areas are very different. For example, the rural 
of Upper Egypt is only 17X of the total rural 
This means that any estimate for a given area 
to be appropriately weighted according to the 
that the area*3 rural population contributes to 
These figures are available from CAPMAS (1976). 


Three, the age-sex structure between the different 
areas must be controlled for if accurate estimates are to be 
made. Age-sex information is only available for 1960 and no 
later. Since the population has not been stable but rather 
growing rapidly {approxiaately 2.1 to 2.5% per annum) the 
proportion of the younger age groups has no doubt been 
increasing, and it is in these very age groups that 
prevalence is highest. However, a quick glance at the age- 
specific distribution between the different study areas 
(seen in Figures 15, 16, 17) would indicate that the age 
structures of the rural populations are remarkably similar. 

Four, an assumption must be made that the 
environmental health conditions are more or less the same 
throughout a given area for which estimates are to be made. 
Especially important are the types of water supply and 
agricultural practices in relation to village type, the two 
environmental parameters shown in this study to be most 
closely linked to schistosomiasis prevalence. 


Collectively, some very broad assumptions must be made 
in calculating estimates from the study sites to be applied 
to the general rural population. The results of the 
examination for ova indicate only the minimum number 
infected which will be an underestimate. The rural 
population of each area has been obtained from CAPMAS (1976) 
which is the most acceptable demographic data available, but 
does not provide age-sex distributions in the population. 
In the delta and Upper-Middle Egypt an assumption is made 
that the population structure and environmental conditions 
are similar throughout the respctive areas, with the 
exception of the Fayoum in Upper-Middle Egypt, which must be 
excluded due to the ongoing schistosomiasis control program. 
However, this assumption is more difficult to apply in the 
Aswan area where environmental conditions and the prevalence 
of schistosomiasis vary widely. Before estimates can be 
calculated in this area, the distribution of the population 

*»non-desert” type villages should 
this demographic information has 
Without this knowledge, it is 
difficult to choose between either "desert” or "non-desert” 
^ representative estimate of prevalence for this area of 
because it is not known how much of the population is 
distributed in "desert” villages where prevalence is low. 

149 


between the "desert" and 
be known. As mentioned, 
never been compiled. 


Assuming that the prevalence in the subsample at Bimban (10) 
is the true prevalence of the ”non-desert” villages of all 
Upper Egypt, then, at the risk of over-estimating the 
prevalence for this area, the proportion positive in the 
Bimban (10) subsample is used for calculating the number of 
infected in this area* 

With the above assumptions and limitations foremost in 
mind and relying on a quote from Moser and Kalton (1972) 
that says ”The accumulated insight of an experienced worker 
frequently merits recording even when absolute documentation 
cannot be given”, estimates have been calculated and are 
shown in Table 53. Almost 6.9 million rural Egyptians were 
estimated to be infected. No doubt this is an underestimate, 
and actually it is only an approximation for which a 
statement of statistical precision cannot be calculated. 
Underestimation also results from not knowing how many are 
infected in the urban areas where transmission is nil, but 
to which large numbers of the rural population, who 
presumably carry with them a measure of infection, have been 
migrating. 

Table 53 

Estimated Prevalences for the Different Downstream Study 
Areas Based on Special Assumptions stated in the text. 


Area 

Rural 

Population 

1976^ 

Estimated 
Prevalence of 
Schistosomiasis 

Estimat ed 
Number 
Infected 

Nile Delta 

11,635,949 

0.420 

4,887,099 

Upper-Middle Egypt 
(minus the Fayoum) 

4,772,647 

0.267 

1,274,297 

Upper Egypt 

3,224,260 

0.227 

731,907 

Total 

19,582,856 

0.352 

6,893,303 


♦ CAPMAS (1976) . 


Farooq, et al^ (1966) and Scott (1937) both increased 
their estimates based on corrections for more than one 
examination for schistosome ova. These corrections would 
increase this approximation of overall prevalence from 0.352 
to 0.415. Either prevalence figure, corrected or 
uncorrected for false negatives, seems high with regard to 

150 















the lower prevalence figure noted in Upper-aiddle and Upper 
Egypt. This is because 59.2% of the rural population lives 
in the Nile Delta where schistosomiasis prevalence has 
always been most intense. 


-§§Sulnr Trends in Schistoso miasi s 


In the Review of Literature, all available past data 
on the distribution and prevalence of schistosomiasis in 
Egypt were presented and assessed fcr methodological 
accuracy and comparability. Whereas it would be desirable 
that more information, especially recent data, was 

9 surprising amount of useful information was 
found. Past data are employed in this section to: 

1) determine the general direction of prevalence trends 
since the 1930*3 in the rural population downstream 
from the AHD, and 

2) use these trends to assess the impact of the 

impoundment of the Nile on schistosomiasis 

prevalence. It has been noted that there has been 
widespread speculation that the prevalence of 

schistosomiasis has been rapidly increasing as a 
direct result of the construction of the AHD. 


The earliest data from 
early part of this century, 
outpatient clinics in the 
Valley were uniformly high 
were freguent and widespread 
unreliable due to selection 


the last century and from the 
collected mostly from hospital 
northern sectors of the Nile 
and suggested that infections 
These prevalence figures are 
biases in the sample. Evidence 


did show that S_. mansoni infections were rare outside of the 
Nile Delta. Scotf^s work (1937) offers the first analytical 
insight into the prevalence and distribution of 
schistosomiasis, and his data are used here as a baseline to 
which all survey data collected since that time are 
compared. 

Long term or secular trends reguire comparisons 
between Scott's (1937) studies and more recent observations, 
and to maximize these comparisons over time, tabulations 
were made separately for each of the three major 
geographical regions of Egypt which have been described. 
The results of this study and others confirm that 
environmental and age^'sex related variables strongly 
influence the prevalence of infection. Significant changes 
in these independent variables have been noticed to occur 
with greater variation between the three major areas than 
between different villages within an area, and when general 
05 ’j^gnia^^s are made, these aspects must be born in mind. 

151 




Table 54 

Nile Delta: Percent Prevalence of 
Schistosomiasis for Selected Years 



Vr> r 


Percent 

Prevalence 


le a r 

Si 

haematobium 

S. mansoni 

Schistosomiasis 

1937 

(Scott) 

53 

54 

83 

1955 

(EMPH) 

46 

31 

ND 

1966 


30 

29 

41* 

(Farooq,et aljj,) 




1976 


30 

20 

42 

Kafr 

El Sheikh 





♦Schistosomiasis figure 

for either 

type of 


infection. 


Table 54 shows the overall prevalence for 
Sji §JL flaansoni^ and schistosomiasis in the 
governorate of Beheira between the years of 1937 and 1966. 
The data from Scott (1937) and from the EWPH study (1955) 
are estimates averaged from eight widely spaced locations in 
this governorate. The overall prevalence (adjusted for 
sampling fraction and age structure) from the Kafr El Sheikh 
study villages, dated 1976 (the year of the field survey) 
was also included as an approximation of current information 
for the Beheira area. Results from Kafr El Sheikh may not 
be truly representative of the conditions in Beheira in that 
S. man so ni prevalence has always been slightly higher in the 


Beheira governorate. 

S, mansoni (20.OX) in 


Therefore, the prevalence of 
Kafr El Sheikh may be a slight 
true prevalence and in turn would 
of those with schistosomiasis, 
Faroog, et al^ (1966a), ’‘Living 
and control divisions (in Beheira) 

in other parts of 

a 


underestimation of the 
affect the estimate 
Otherwise, to quote 
conditions in the rural 

do not differ markedly from those observed 

rural Egypt both recently (Zaghloul, 1963) and about 
generation ago, (Headlee, 1933)”, these two governorates are 
in many respects quite similar. Still it could be argued 
that too many factors are not controlled for to make precise 
comparisons between these studies. Particularly sensitive 
is the question of differences in methodology employed by 
the respective investigations. The EMPH(1955) study was in 
fact designed after Scott’s (1937) work and was implemented 

152 





















in an attempt to establish a long range plan for routine 
surveillance, which unfortunately has not been continued. 
Methodologies used in the study headed by Faroog, and 
Nielsen,^ (1966) and used in this study are in essence also 
very alike. While no quantitative evaluations of the 
different laboratory techniques used are available, the 
basic approach employed by all of these investigations, 
i.e. the examination of urine or stool sediment for 
characteristic ova, adhere to similar basic methodological 
principles. In addition, the techniques for identification 
of schistosome ova are not sophisticated, delicate, or, for 
that matter, sensitive, procedures. The schistosome ova are 
large, averaging 145 microns in length, and are in no way 
difficult to speciate or to distinguish from other 
parasitic ova or cysts, or detritus. However, it is possible 
that qualitative differences could be found even between two 
laboratories using the same procedures. Also, the focal 
nature of the disease indicates that other different yet 
valid estimates could be easily obtained by sampling 
different villages. In face of these limitations the 
evidence of this and previous studies remains overwhelmingly 
convincing. There is not one example in four completely 
independent observations, made over a span of 39 years in 
the Nile Delta, to indicate an increase in the prevalence of 
species. Instead, there appears to have been a 
longterm downward trend in schistosomiasis prevalence, over 
the past four decades, perhaps tapering off somewhat in the 
last ten years. 


Table 55 shows the overall prevalence of 
S. haemat obium in Upper-Middle Egypt in the governorates of 
Beni Suef fcr~1937, 1955, and 1976, and in 1968 for the 

same assumptions and limitations 
from Upper-Middle Egypt as were 
but in this region the downward 
marked. The prevalence of 
schistosomiasis has dropped from 82% in 1937 to 21% in 1976. 
Again the evidence is clear and convincing, i.e., there is 
strong evidence of a decrease and certainly no indication of 
an increase in prevalence in Upper-Middle Egypt since 1937. 


governorate of Minya. The 
^Fply these observations 
stated for the Nile Delta, 
trend is even more 


In the remaining area. Upper Egypt, the situation is 
not as clear cut. Although speculations concerning the 
effect of the AHD on schistosomiasis were most often 
sweeping statements such as those made by Van der Schalie 
(1974), Fogel, et al^ (1970), and Furnir (1975), more 
specific predictions were made by Farooq (1967). The 
evidence already stated does not support the generalized and 
comnletelv unfounded statements such as *^schistosomiasis is 
ScJe prevalent now than ten years ago- (Furnir, 1975), but 
Farooq's 1967 stateoent that 2.65 nillion new cases would 
result in areas to be converted to perennial irrigation 

requires a closer look.. 


153 





Table 55 

Upper-Middle Egypt 

Percent Prevalence of S. ha ema tobium by Selected Years. 


Percent 

Year Prevalence 

1937 (Scott) 82 

1955 (EMPH) 36 

1968 (Hamman# et 35 

1976 BeniSuef 27 


Although Faroog (1967) did not specify the area that 
was to be converted to perennial irrigation it can safely be 
assumed that he was referring to Upper Egypt, as by 1967 all 
other areas in Egypt had long since been using perennial 
irrigation schemes. According to the rural population 
figures from CAPMAS (1976) shown in Table 52, there are 3.2 
million rural inhabitants in Upper Egypt. In essence this 
is the population at risk. Faroog (1967) indicated that 
before the AHD was built the overall prevalence in this 
population was 536. 

First, there is good evidence that the prevalence of 
schistosomiasis was already rising in Upper Egypt long 
before the AHD period. By 1955 the prevalence of 
schistosomiasis in the rural population of Sohag, where 4731 
of the total population of Upper Egypt resides, had risen 
from 3% to ^2%, and in Aswan the prevalence had also risen, 
in this case to 23% (Wright, 1973). After 1955, the 
prevalence had remained low (4%) only in Qena. There is no 
information on prevalence for Upper Egypt between 1955 and 
when the AHD was built. It is doubtful, however, that the 
prevalence remained low throughout this period, as it is 
fairly certain that pumps (the floating variety mentioned 
earlier) and canals were installed previous to the major 
schemes implemented after the AHD. 

Faroog*s (1967) estimate of 2.65 million new cases 
translates to 82% of the total rural population of Upper 
Egypt. While it is possible that increases in prevalence 
occurred in limited areas of Upper Egypt as a result of the 
irrigation expansion related to the AHD construction, it is 
doubtful that 82% of this population is positive for 
schistosome ova. Current, but rather limited, information 
on prevalence in Upper Egypt does not support this 

154 














prediction. Dazo and Biles (1972) found an overall 
prevalence of 38% in their sample from Upper Egypt, but as 
pointed out these figures are biased because of self¬ 
selection, which, incidentally, usually tends to elevate 
prevalence estimates. At any rate they did not find even 

number infected that was projected by Farooq 
(1967). The current prevalence figures used for general 
estimates in Upper Egypt collected by this study are from 
the Biffiban (10) subsample. For reasons already discussed, 
the Biffiban (10) subsample was used as a figure for 
estimating prevalence in this region. This figure is also 
lower, by almost four times, than Faroog's (1967) 
predictions. Admittedly, the current information on 
prevalence in Upper Egypt is not extensive, but it is 
difficult tc imagine that the environmental conditions and 
prevalence of schistosomiasis in Upper Egypt are now what 
they were in the Nile Delta and Upper-Middle Egypt 40 years 
ago. In this same vein it is interesting that in 1937 
Khalil and Azim (1937), during their original work on the 
effects of irrigation on schistosomiasis transmission, noted 
an increase in prevalence in Bimban (10) which had also been 
included in their studies, from 2% to 64% (see Table 1). It 
would seem that, in Bimban (10) at least, there was a burst 
of infection following conversion of the area to perennial 
irrigation. Since that time, more current data from this 
study suggest that the prevalence has fallen to almost a 
third of what it was 39 years before. 


The Kom Ombo plain was the first site in the whole of 
Upper Egypt to be converted to perennial irrigation and was 
a focus of high prevalence in an area that was predominantly 
lew during the 1930*s. It is hypothesized here that 
following conversion of a given area in Upper Egypt to 
perennial irrigation, regardless of the specific type of 
scheme used, there was a sharp rise in the prevalence of 
schistosomiasis, followed by a tapering off, most likely in 
the 1960*s or 1970*s, similar to the other sectors of the 
Nile Valley to the north. Furthermore, the prevalence in 
Upper Egypt at the time of the survey, in the agricultural 
villages, is at about the same level as seen currently in 
Upper-Middle Egypt, but future surveillance studies are 
needed to confirm this. It should be noted that prevalence 
information has been badly needed in this area of Egypt for 
a long time. It is because of the systematic exclusion of 
Upper Egypt in field studies in the past three decades that 
the exact developments, in terms of changes in prevalences 
and the causative role that the AHD complex has played, 
cannot be completely elucidated. However, the greater body 
q£ evidence dees not support the many predictions that the 
high prevalence of schistosomiasis in Egypt, and indeed it 
is still very high, is the result of the formation of Lake 

irrigation expansions. Rather, the 
limited role, if any, over the past 
the prevalence of schistosomiasis. 
155 


Nasser and the related 
AHD seems to have had a 
12 years in increasing 


If there were related increases they were limited to 
selected areas of Upper Egypt, with undetectable effects on 
the northern sectors of the Nile Valley in Egypt* 


The first hypothesis of 
Evidence obtained from the downs 
the historical data strongly indi 
the prevalence of schistosomia 
there have been overall inc 
schistosomiasis, in the downstrea 
be supported. 


this study is rejected, 
tream study sites and from 
cate an overall decrease in 
sis. The hypothesis that 
reases in prevalence of 
m rural population, cannot 


In CO 

remains a 
especially 
lake. The 
snail vecto 
made to the 
1974) the s 
has been 
potential p 
is strongly 
changes. 


nciuding, it should he understood that there 
potential for the spread of schistosomiasis, 
into the future reclamation 
lake has formed a huge new 
r proliferation. According 
lake (Da^o and Biles, 1971, 
pecies Bul inu s. the vector for S_. h aem atobium^ 
found throughout. These aspects pose future 
roblems for which frequent and tight surveillance 
recommended as a measure to recognize early 


areas and in the new 
habitat favorable to 
to a number of trips 
1972; Scott and Chu, 


Ch an ges and 


Schisto somi asis 


When the prevalence rates for Egypt cited in this 
study are used to show trends, the impact of population 
growth on the total number of cases of schistosomiasis is 
revealed. Because of the increase in population, the actual 
number of cases can increase without a change in prevalence 
or a change in the geographical distribution of the disease. 
This is an additional dimension of the impact of the disease 
and can be illustrated as follows: 


In 1937, Scott (1937) estimated that 7.15 million 
persons in all of Egypt were infected with either one or 
both species of Schistosoma. (This included 0.5 million 
persons infected in urban areas. When they are excluded the 
estimate falls to . 6.65 million cases.) The population at 
that time was 15.23 million persons, making the prevalence 
46.951S (see Table 56). If we assume that there has been no 
change in prevalence since Scott’s (1937) time nor any 
change in distribution, then 46.95% of the present 
population would be infected; that is, 17.95 million 
infected out of 38.23 million in Egypt in 1976. The 
difference would be 10.7 million more cases of 
schistosomiasis when compared with the number infected in 
1935, a result directly related to a rapidly growing 
population. 


has been a change in 


If we assume that 


there 

156 







Table 56 

Table Showing the Results of Certain Assuraftions 
Made on the Prevalence of Schistosomiasis in 
Respect to Population Changes in Egypt* 


Area and Year 

Population 

(1X106) 

Number 
Shedding 
Ova (1X10«) 

Percent 

Prevalence 

1935 Entire 

Nile Valley 
and Delta 

15.23 

7. 15 

46.95 

1976 Entire 

Nile Valley 
and Delta 

38.23 

17.95 

46.95 

1976 Assyut to 

Aswan Only 

4.27 

2*0 

46.95 

1976 "Adjusted” 
Entire Nile Valley 
and Delta 

38.23 

19.95 

52.18 

1976 All Rural Egypt 

19.58 

7.13 

25.9 


distribution in the area south of Assyut to Aswan, where the 
prevalence in 1935 was in the neighborhood of 1-2%, then 
there are even more cases that would have to be added to the 
current ^estimated" 17*95 million infected* As pointed out, 
there is good reason to think that S*^ haemato bium has 
invaded this southern area of Egypt, as the land there is 
now under perennial irrigation* (Sporadic S^ mansoni 
infections would not make a significant contribution to the 
overall prevalence.) Currently, there are 4.25 million 
persons living in this area between Assyut and Aswan, and if 
the overall figure of 46.95% is used to estimate the number 
of those infected, then the number of cases will equal about 
2 million. That would raise the total cases from 17.95 to 
19*95 or 20 million cases in 1976. When compared to the 
figures for the 1930‘s it would be a staggering 12.7 million 
more cases than the 7*15 million estimated in 1937. 

However, there is no evidence that the prevalence has 
been maintained at the levels seen by Scott (1937) in the 
1930*s. There are no data in this study that would indicate 
an overall increase in prevalence* Instead, the many 

that have been cited overwhelmingly point to a 
decrease. In addition, prevalence in the Fayouro is 

reportedly low at 8.1%, and there is an undetermined number 

157 


















in Upper Egypt living in ”desert” villages where prevalence 
is also low. 

It must also be remembered that prevalence estimates 
for Egypt are based on findings in rural areas and that very 
limited information is available for urban populations. 
This is important because the urban populations have been 
growing rapidly^ at more than twice the rate of the rural 
areas of Egypt, and in the urban areas transmission is nil. 
In 1935, 7755 of the total population in the Nile Valley and 
Delta was rural. Now it is just over 5315 or about 20.44 
million persons. At least 36. 555 of this rural population 
(not including the Fayoum population) would have to be 
shedding ova to equal Scott’s (1937) estimates in 1937. 


This, of course, is very near the correct approximated 
prevalence calculated by this study for the rural population 
in the Nile Valley. The combination of declining 
prevalence, rural-urban immigration, and increasing 
population in the last 40 years has resulted, at least in 
the rural areas, in keeping the number of cases of 
schistosomiasis constant. From the urban perspective, an 
observer that has been seeing tens of thousands of new 
schistosomiasis cases (as rural-urban immigrants) has 
probably blamed the AHD more than once for this alarming 
increase, when actually the real cause for increases in 
schistosomiasis in urban Egypt is in migration, not the 
Aswan High Das. 


Whatever the exact figures, schistosomiasis is 
undoubtedly a tremendous health burden for the Egyptian 
rural population. The numerous age-prevalence curves cited 
here indicate that many persons who are not currently 
shedding ova have been previously and may develop chronic 
manifestations. Thus, trends based on ova detection in 
excreta do not render an exact figure for the total number 
actually infected but result rather in an underestimate. 
Nor is it known how many new urbanites are infected. Trends 
of this type only suggest relative changes in the number 
infected, and, in the case of rural Egypt, they do indicate 
a decrease. These points are important in view of the 
speculation concerning the impact of the AHD on the 
transmission of schistosomiasis. The question of the future 
impact of the Aswan High Dam on changing the transmission of 
schistosomiasis still remains. It is too early to know what 
changes will occur in reclaimed lands or in the new lake. 
The exact distribution of ^ mansoni infections also remains 
to be resolved. Additional data are clearly needed. A 
review of trends presented in this study does show that all 
current results must be viewed against the historical 
context in which schistosomiasis has existed in Egypt for 
centuries. 


158 



Ihe Nubian Stud^ 


Prevalence data for schistosomiasis were collected 
also in Nev Nubia* The objective was to determine if 
changes had occurred in the Nubian population after 
relocation* Previous to the filling of Lake Nasser and the 
inundation of the Nubian homes these people were living in 
an area over 450 kilometers long. Table 39 gives an 
indication of what some of the environmental conditions were 
in respect to housing and water supply. The majority 
obtained their water from the Nile, even when the Kanoose 
tribe was included in the total, Abdady and Shalash (1966) 
noted that many of the pumps in the Fadiga area were broken 
which means that many more families were taking their water 
from the Nile than indicated. After resettlement the Nubian 
water supply was improved, as has been pointed out. 


This is one possible reason why prevalence of 

schistosomiasis has decreased in this population. The 
results from this study conclusively show that prevalence 
has dropped in the Nubian population. 2awahry (1964) found 
12 years previous, in the same villages (not including 
Kalabsha (9) and Tushka (6)), that the overall prevalence 
was 15.2%. The adjusted prevalence from their study 
(including Kalabsha (9) and Tushka (6)) was 7.2%. If 

Kalabsha (9) and Tushka (6) were not included in the overall 
prevalence figures the improvement would be even greater. 
This is because Kalabsha (9) had an unusually high 
prevalence* A comparison between Zawahry*s (1964) results 
and this study by village (compare Table 51 with Table 16) 
shows in every case that prevalence has dropped in the sites 
surveyed by Zawahry (1964). The most dramatic changes are 
seen in Ballana (5) and El Malki (9) • 


Aside from the improvement in water supply, a more 
important parameter contributing to the fall in prevalence 
is the change in irrigation practices following relocation. 
The Nubians bad begun irrigation development in the 1950’s 
in selected areas. Little development had occurred in the 
northern tribes because the low lands in their area had been 
inundated by the rising waters trapped by the first Aswan 
dam built in 1910. Most of the members of this tribe have 
had to relocate twice this century, the first time to higher 
and verv hilly ground, but within the same general 
^egiLrthe sLond time to New Nubia. The hilly areas of 
the first relocation were unadaptable to irrigation schemes, 
and thus Tawahry (1964) found a low prevalence of 

schistosomiasis. Since the Nubians have moved to Korn Ombo, 
exposure to irrigation systems has lessened. One 
reason in addition to improved water supply is that the new 
yij^Xages were constructed strategically at a distance from 

^Korn Ombo plain. Water from the standpipes 
is far more convenient than that from the canals. Perhaps 



even nore inportantly^ the Kubians were compensated by the 
government viith land in the Kom Ombo, As land owners^ the 
Nubians can and do hire locals to till and tend the fields. 
One last additional aspect that may also have contributed to 
controlling prevalence in the resettled Nubians is that 
schools, clubs, social centers, electricity, and rural 
health units and centers were all built into the resettled 
sites. 


The findings at Kalabsha (9) remain an enigma. The 
unusually high prevalence of infection is unique to Nubia. 
The distribution of the infection between the sexes has not 
been seen in any of the other samples in this study or, for 
that matter, in any other study. 

In the general survey of Nubia, there were no 
outstanding environmental or demographic features in the 
Kalabsha (9) study site that would provide an immediate 
answer as to why Kalabsha (9) had a much higher prevalence 
of schistosomiasis than any of the other villages sampled in 
Nubia. The age structure was not unique. The age-specific 
prevalence of Kalabsha (9) was proportionally higher in the 
middle age groups when compared to the results from the 
other Nubian sites, which typically fell in prevalence 
following the late adolescent and early adult age groups. 
It is possible that older Nubians who had previously been 
employed in the Nile Delta (or in ether northern sectors of 
Egypt) were returning and brought with them infection 
aeguired outside of Nubia. The observation that the 
malerfemale ratio has increased since resettlement indicates 
that many males have returned after resettlement. Fahim 
(1974) also noted that many of the Nubians who had migrated 
to the north for work were returning to join relatives who 
were now more accessible. This explanation seems unlikely, 
however. If it were true that returning Nubians brought 
schistosome infections with them, one would expect to see a 
similar elevation of prevalence in the other Nubian villages 
sampled. The general low prevalence detected in Nubia does 
not support this explanation. 

Zawahry*s (1964) results indicated that the tribe to 
which the Nubians of Kalabsha (9) belonged had had a low 
prevalence of schistosomiasis (4.1^). However, Zawahry also 
noted ten years previously, in 1954, that El Dakka, a nearby 
village belonging to the same tribe, had a perennial 
irrigation project, and had a high prevalence of 
schistosomiasis. Even if it could be shown that Kalabsha 
(9) had had an elevated prevalence before being moved and 
had simply carried the infection over to the new site, it 
would not explain how the prevalence has been maintained for 
twelve years in an area of predominately low prevalence. 

Water and wastewater practices in Kalabsha (9) did not 
differ significantly from the^^other Nubian villages, all of 


which were provided by the governnient resettlement program 
an are very similar. Actually, more homes in Kalabsha (9) 
had electricity (57,hX) and cooked with karseen (94%) than 
in any of the other villages, indicating a superior economic 
status. Usually economic status correlates inversely with 
prevalence (Farooq, ^ al,, 1966), 


It is not known whether or not the people of Kalabsha 
(9) cultivate their own land or hire local saidies (Upper 
Egyptians) as the Nubians generally do (Fahim, 1974), If 
they do attend their own fields, the risk of exposure is 
probably much greater. This is an important parameter for 
fcllow-up studies^ which are needed before an accurate 
evaluation of this anomaly can be established. 

Finally, the results from Kazan Sharq (1) in Aswan 
must be considered. This village is populated by Nubians of 
the Kanoose tribe. Because it is located just north of the 
old Aswan Dam it represents a Nubian village which did not 
have to be relocated, either in 1910 when the old Aswan was 
built, or later when the AHD was erected. 


As shown in Table 35, the prevalence of 
schistosomiasis in this village is 6.9%, typically low for a 
village with no irrigation schemes and only the Nile as a 
water source. There were no other environmental or 
demographic parameters in Kazan Sharq (1) which seemed out 
of place to what might have been expected if this village 
was studied 12 years previously when Zawahry (1964) 
completed the study on the Nubians before they were 
relocated. Indeed^ there is no reason to believe that this 
village is not representative of conditions in Upper Egypt 
when basin irrigation existed throughout, or even of earlier 
periods. The results from Kazan Sharq (1) could easi ly be 
considered as an ultimate baseline for schistosomiasis 
prevalence in Nubia, Upper Egypt, or Egypt as a whole before 
development of modern agricultural techniques. The 
implication is that the Nubians in their original state, 
before there was any irrigation development by the southern 
two tribes very probably had a low prevalence similar to 
that in Kazan Sharq (1). During the 1950»s, limited 
irrigation development resulted in sharp increases in the 
regions where these schemes were installed. Now, following 
relocation, the Nubians are, for the reasons stated above, 
isolated from sites where there is optimal transmission, 
(with the apparent exception of Kalabsha (9)) and, as a 
population over the past 12 years have been losing their 
infections. Part of this loss results from the dilution of 
an infected population with successive cohorts that remain 
free of infections. This would explain why the age 
prevalence curve for Nubia is not as marked in the younger 
age groups as would be expected under more stabilized 
conditions. Also, loss of infection could be occurring 

spontaneously and as a result of specific therapeutic 

^ 161 



treatment. Spontaneous loss probably does not account for a 
significant proportion, especially in the adult age groups, 
but little is known about this aspect of the disease. Loss 
of infection due to treatment may also be limited. Specific 
treatment has never been popular because of various 
reactions to the therapeutic agents available. The 
observation is that over a period of 12 years prevalence in 
the southern two tribes has dropped from 23% to less than 
551, It would seem in a period of 12 years, or perhaps less, 
a population no longer exposed is capable of shedding a 
substantial proportion of its infection. Whereas there have 
been many observations to show how quickly prevalence in a 
susceptible population can rise from a very low point to 
where virtually the entire population is infected (the 
results in Table 1 are an example) there is little or no 
data to show how quickly a population will cure itself. It 
is possible that the observations made in the southern two 
tribes, represented by El Malki (7) and Ballana (6), are an 
indication of this. It would be interesting to know what 
the real loss rates were. Predictions of decreases in 
prevalence following environmental control measures are 
badly needed, and, without this measure, it will be 
difficult to evaluate such projects. 

The second hypothesis of this study is also rejected. 
The overall prevalence in the resettled Nubian population, 
Kalabsha (9) included, has decreased. An overall prevalence 
greater than 15% would be necessary before an increase could 
be considered. The estimated overall prevalence was on ly 
8 . 8 %, 


The decline in schistosomiasis described here is 
encouraging. However, there is no evidence that indicates a 


continued decline in 
occur and must 
schistosomiasis in 
this study demands 


the prevalence, 
be followed, 
over 6.9 million 
continued concern. 


Changes are likely to 
The infection with 
Egyptians estimated by 


162 


REFERENCES 


Abdallah, A. 1S73* A resume of some pilot control projects 

out in Egypt in the past 20 years. Jo urna l 

i]i£ Public Health Association 48: 

290-307. - “ 

Abdel-Salam, E. and Abdel-Fattah, M. 1972. Prevalence and 
morbidity of Schistosoma Haematobium in Egyptian 

children. A controlled study. American Journal 
Tropical Medicine ^d Hysifne 26 (3): 463-469. 

Alamy, M.A. and Cline, B.L. Prevalence and intensity of 

§cfei§i 2 Soma haematobium and m ans oni infections in 
Qalyub, Egypt. Ameri can Journal of Tropical 
S^dicine and Hy^ie^ 26 (3) : 470-472. 

Allam, F.A.; Hassanien, F.; and Hammam, H.M. 1974. 

Bel ationsh ip between £ure Sch isto soma hae matobium 

infeeti on in 0p per Egypt and irrigation sys tems. 

Amin, H. and Zaghloul, H. F. 1959. The present status and 
programs of environmental sanitation in Egypt, 

dgurnal of the E gyptian P ubl ic Health A ssocia t i on 34 
(1): pp. 1-35. 

Ansari, N. 1973. Epidemlolcg y and contr ol of 

Schistosomiasis (Bilharziasis) . Baltimore: 

University Park Press. 1973. 

Attiah, M.A.; Kholy, A. M.; and Omran, A.E. 1962. Computed 
incidence in chronic diseases by applying the life 
table approach to prevalence data. Jo urn al of the 

Publ ic H ealt h Association ^2* 217-23 9. 

Ayad, N. 1966. The national campaign against Bilharziasis 
in the United Arab Republic. Pf lanzens c hutz- 
Nachrichten. 29: 1-6. 

Ayad, N. 1969. The anti-bilharzial campaign in O.A.R. 

Proceedings of the 1st Nati ona l S ymp osium on 

Ministry of Scientific Research, 

Cairo, 0.A.B. 

Azim, M.A. 1935. The epidemiology and endemiology of 
Schistosomiasis in Egypt. Jeurn^ of the Egyptian 
Associa tion . 18: 215-227. 


163 







































Bachmann, G* 1965. 

pur ific a tio n 

Sliifii ll§lz 


Assig nm ent report;^ Se wer age^ sew age 
a nd pum p in g 
(EM/ES/ 70. 4.65) 


Barlow^ C.H. 1939. Seasonal incidence of infestation of 
the snail hosts with larval Hurran schistosomes. 

dogcp al of Hygiene 30: 73-81. 


Eell^ D.R.; Farooq, M.; Samaan, S.A.; Mallah, M.B.; and 
Jarockiy, L. 1967. transmission of urinary 
schistosomiasis after the introduction of snail 
control. American Jo urnal of tropic al Medicine and 
Parasit olo gy JJ: 422-428. 

Elagg, W.; Schloegel/ E.L.; Mansour, N.S.; and Khalaf, G.I. 

1955. A new concentration technic for he 
demonstration of protozoa and helminth ova in feces. 
American J ourn al of Trop ical Medicii^ and Hygiene 4: 
23-287 


Eruijning^ C.F.A. 1971. Water, health, and economic 
progress. Tra nsactions of the Hoyal Socie ty of 
Tropi cal Medicine and Hyg iene 65: 47-52. 

CAPMAS. 1960. Census of population. Volume II. General 
Tables. United Arab Republic, Department of 

Statistics and Census, Cairo. 

CAPMAS. 1976. The preli minary results of the several 

p opul ation and housing cen sus, 22/23 No vem ber 1976 
is g g yp i* Central Agency for Public Mobilisation 
and Statistics, Cairo. 

Carter, 1. J. 1969. Development in poor nations: How to 
avoid fouling the nest. Science 163: 1046-1048. 

Chandler, A.C. An evaluation of the effects after two 

years of sanitary improvement in an Egyptian 
village. J our nal of the Hoyal Egy pti an Medical 
Association 36: 257-265. 

Cheever, A.W. 1968. ”A quantitative post mortem study of 
Schistosomiasis mansoni in man." American Journal 
fropical Medicine and Hygiene 17: 38-64. 

Cheever, A.H.; Kamel, I.A.; Elwi, A.M.; Mosimann, J.E.; and 
Danner, R. 1977. Schistosoma m ans oni and 
Si ha emat o bium infections in Egypt. II. 
Quantitative parasitological findings at Necropsy. 
Am erican Journal of Tropical Medicine anl Hygiene 26 
(4) : 702-726. 

Dawood, M.M. 1951. Bilharziasis in Bilad El Nuba in Egypt. 

Journal of the Egyptian Medical Association 34: 660. 

164 




















































Dazo, B.C, Biles, 1970. Schistosoiaiasis in the 

Kaicji Lake area, Nigeria. Report on a survey made 
in 1970. WHC/SCHISTO/72.21. 

Lazo, B.C. and Biles, J.E. 1971. The schistosomiasis 
situation in the Lake Nasser area, A.R.E. WHO/ 
SCHISTO/72. 23. 

Cazo, B.C. and Biles, J.E. 1971a. Follow-up studies on the 
epidemiology of Schistosomiasis in the Kainji Lake 
area, Nigeria. WHC/SCHISTO/73.29. 

Lazo, B.C. and Biles, J.E. 1972. The present status of 
schistosomiasis in the Nile Valley north of the 
Aswan High Dam, (Unpublished document PD/72.14). 

Dazo, B.C. and Biles, J.E. 1972a. Investigations on 
schistosomiasis in Ghana. Report on a visit to 
Project IR-0659. PD/72.12. 

Dazo, B.C. ; Hairston, N.G.; and Dawood, I.K. 1966. The 
ecology of Bul inus truncatus and Bio mphalaria 
alexan drina and its implications for the control of 
Bilharziasis in the Egypt-49 Project area. Bull etin 
World Heal th Organization 35: 339-356. 


Dawood, I.K. ; Dazo, B.C.; and Faroog, M. 1966. Large- 

scale application of Bayluscide and Sodium 

Pentachlorophenate in the Egypt-49 Project area. 
Bulletin of the W orld Health Organi za tion 35: 
357-367T 


Dimmette, R.Hetal. 1956. 

infected with Sj. 

Pathology 


Survey of 
haematobium. 


an Egyptian village 
American Journal 


25: 1032-1042. 


ErtH, 1975. Fayo um C ont rol Project f or Bilh arziasi s. 

EMPH. 1955. Results of a country-wide schistosomiasis 
survey By Wright, W.H. in Epidemiology and control 
of sc histos omiasis ( Bilh arziasis), ed. Ansari, 
Baltimore: University Park Press. pp. 42-48. 


N. 


Fahio, H. «. 1974. The New Nubian Resettlement in Egypt: A 

Descriptive Report Field Research Projects. Coconut 
Grove, Hiami, Florida, 

Farid, M.A. 1975. The Aswan High Dam Development Project. 

In Man-made L akes and Humj^n H ealt h, ed. Stanley, 
~ F. and Alpers, M. P. Academic 

Press. London. pp« 89-102. 

Faroog, M. 1964. New partnership in schistosomiasis 

^control: socioeconomic overplays with bilharzia. 

165 























J ournal of Tropical liedi cine and Hygiene 62: 265. 

Farooq^ M. 1966. laportance of determining transmission 
sites in planning Bilharziasis control. American 
Journal of Epidemiology 83: 603. 

Farooq, M. 1967. Progress in Bilharziasis control: The 
situation in Egypt. WHO Chroni cle 2^: 175-184. 

Farooq^ M. 1973. Historical development. In E pi demio log y 

Co ntr ol of S chi stosomiasis JBil harz ia sis )^ 
ed. Ansari, N. Baltimore: University Park Press. 

pp. 1-16. 

Farooq, H. and Hairston^ N.G. 1966. The epidemiology of 
Sch ist osoma ha emato bi um and S^ JAHSoai infections in 
the Egypt-49 Project area. IV. Measurement of the 

incidence of Bilharziasis. Bulle tin of the World 

Health Orga n izat ion 35 : 331-338 

Farooq, fl.; Hairston, N.G.; and Samaan, S.A. 1966. The 
effect of area-wide snail control on the endemicity 
of Bilharziasis in Egypt. Bul letin of the World 
Organi zat ion 35: 369-375. 

Farooq, M. and Mallah, M.B. 1966. The behavioural pattern 
of social and religious water-contact activities in 
the Egypt-49 Bilharziasis Project area. Bulletin of 
th e World Health O rga nization 35: 377-387. 

Farooq, M.; Samaan, S.A.; and Nielsen, J. 1966b. 

Assessment of severity of disease caused by 
S j h ae m ato bium and S_j, mansoni in the Egypt-49 
Project area. B ullet in of the W orl d Health 
Org anizatio n 35: 389-404. 

Farooq, H.; Nielsen, J.; Samaan, S.A.; Mallah, M.B.; and 
Allam, A.A. 1966. The epidemiology of Schi s tos oma 
haemat obiu m and 5^ mansoni infections in the 

Egypt-49 Project area: 2. Prevalence of 

bilharziasis in relation tc personal attributes and 
habits. Bulletin of the World Health Organization 
35: 293-3187 

Farooq, M.; Nielsen, J.; Samaan, S.A.; Mallah, M.B.; and 
Allam, A.A. 1966a. The epidemiology of Sch ist osoma 
haemat obiu m and S^ MSsoni infections in the 

Egypt-49 Project area: 3. Prevalence of 

bilharziasis in relation to certain environmental 
factors. Bu lleti n of the World Health Organization 
35: 319-330. ~ 

Farooq, M. and Nielsen, J. 1966. The epidemiology of 
Sc hi stospma h aem atobium and S^ mansoni infections in 

166 











































the Egypt-49 Project area: 1. 
and procedures for measuring 
bilharziasis. Bullet in of 
gg^anizatioD 35^ 281-292, 


Sampling techniques 
the prevalence of 
the W orl d Health 


Farooq^ H, and Hairston^ N.G, 1966. The epidemiology of 
§gfei§i2soraa ha efflatobi um and ma nsoni infections in 
the Egypt-49 Project area. IV. Measurement of the 
incidence of Biiharziasis. Bulle tin of 52X1^ 

Organization 35: 331-338. 


Fernea, R.ft. and Gerster, G. 1973. Nubians in Egy pt . 

Pea cefu l Peop le. Austin: University of Texas 

Press. 


Fogel, L.J.; Sullivan, D.; and Maxfield, M. 1972. 

E pi de miol ogical c onse quences of S chis to som iasis in 
ashington, D.C. 


Freeman, P.H. 1974. The e nvir onmental il£act of a l arg e 

rese rvo ir: GuIdelines for £oiicy and 
planning: Ba sed on a case stud^ of Lake Vol ta^ Ghan a 
in J9JJ and 19 74. Office of International and 
Environmental Programs, Smithsonian Institution, 
Washington, D.C. . 

Furnia, A.H. 1975. Sy ncrisis: the dyna mics of health XVI: 

Th e Arab Rep ubl ic of Egy£t^ U.S. Department of 
Health, Education, and Welfare. Public Health 
Service. Office of International Health, Division 
of Program Analysis. 


Gilles, H.M.; Zaki, A.A.; Soussa, M.H.; Samaan, S.A.; 

Soliman, S.S.; Hassan, A.; and Barbosa, F.; 1973. 
Results of a seven year snail control project on the 
endemicity of Schistos oma hae mat obi um infection in 
Egypt. Amer ican Jo urna l Tro pic al M edicin e and 
P ar asitology,. 67 (1) : pp. 45-65. 

Gremliza, F.G.L. 1965. A method for measuring the quality 
of village conditions in less developed rural areas. 
A m e rican J ournal of Publ ic Health 55: 107-115. 

Halawani, A. 1957. Mass treatment and control service of 
Schistosomiasis and endemic diseases in Egypt. 

Egypt ian Public Health Associatio n 

32: 123-135. 

Hairston, N.G. 1965. An analysis of age prevalence data 
by catalytic models. Bulletin of the World Health 
Organization 33: 163-175. 

Eaiaman, H. 11.; Allan, F.A.; Hassanein, F.; and El Garby, 
M T 1975. Relationship between pure 

167 


















































Schis tos omiasis haemato bi uro infection in Upper Egypt 
and irrigation systems. The Ga zett e of the Eg_yptian 
Paed iat r ic Ass oc i atio n. July-Oct. 23 (3'*'4) : 

pp. 201-277. 

Beadlee, W.H. 1933. Epidemiological study of helminth 
infections in an Egyptian village. Soil pollution 
and soil infestation. Ame ric an Jo urnal of Higiene 
18: 695-711. 

Harinasuta^ C.; Sornmani, S.; and Kitikoon, V. 1972. 

Infection of aquatic hydrobiid snails and animals 
with Schistosoma japon icum-like parasites from 
Khang Island, Southern Laos. Transa cti ons of the 
Society of Tropical Medicine and Hygiene 66: 

184. 

Hassouma, M. 1975. BeliefS|^ practices^ env ironment and 

§fl®cti^ the survival, g rowth # and 
yo^nq Egyptian children. The 
Egyptian Institute of National Planning, Cairo. 

Heyneoan, D. 1971. Mis-aid to the Third World: Disease 

repercussions caused by ecological ignorance. 
Canad ian Jou rnal of Public Heal th 62: 303-313. 

Hiatt, R.A. 1976. Horbidity from Schis t osom a mansoni 

infections: an epidemiologic study based on 

quantitative analysis of egg excretion in two 

highland Ethiopian villages. Am erica n Journal of 
Tropical Med icine and Hygiene 25 (6): 808-817. 

Hira, P.H. 1969. Transmission of Schistosomiasis in Lake 
Kariba, Zambia. Nature 224: 670-672. 

Hussein, M. 1972. Unpublished mimeograph on health 
manpower. High Institute of Public Health, 
University of Alexandria, Alexandria, Egypt. 

Imevbore, A.M.A. 1975. The Kainji Dam and health. In Man- 

and Human Health, ed. Stanley, N.F. and 
Alpers, M.P. London: Academic Press, pp. 209-220. 

Jordan, P. 1972. Schistosomiasis and disease. In 

Schistosomiasis, ed. Miller, M.J., Tulane 
University, New Orleans, pp. 17-23. 

Kamal, A.M. 1952. Bored-hole latrines in Sirs-El-Hayan 
district. J ourna l of the Egyptian Public Health 
Association 3J (2): 53. ~ 

Knight, H.B.; Hiatt, fi.A,; Clure, E.L.; and Ritchie, L.S. 

1976. A modification of the formal-ether 
concentration technique for increased sensitivity in 

168 





































detecting Sc histoso^ aansoni eggs* A me rican 
9^ X£QPicaI Medicine and Hygiene 2 5 (6) : 

818 * 

Khalil, M* 1949* The national campaign for the treatment 
and control of Bilharziasis from the scientific and 
economic aspects* Jour nal of the E^^ptian Medical 
Issocia^ipn J2: 817-856* 

—-•1927* Report and n ot es of the Publ ic Health Lab 

No* Cairo * * 

Khalil, H* and Azim, M.A* 1935. The introduction of 
Schistosoma infection through irrigation schemes in 
the Aswan area, Egypt* Journal of the Egyptian 
Medical Association 18: 371-496. 

Khalil, M* and Azim, M.A. 1938. Further observations on 
the introduction of infection with haema tobium 
through the irrigation schemes in Aswan province. 
Journal of the Eg yptian Medical Association 21: 
95-101* 

Lanoix, J*N. 1958. Relation between irrigation 

engineering and Bil har ziasis* Bullet in of the World 
Healt h Orga ni zation 18 : 1011-1035. 

leiper, R.T. 1915. Report on the results of the Bilharzia 
mission in Egypt, 1915. Part I* Transmission. 
Jou rnal of the Royal Army M ed ical Corps 25: 1-55 

MacDonald, G. 1955. Medical implications of the Volta 
River project. T ransa ctions Roi§l Society of 
Tropical Me dicin e and Hygiene 49: 13-27* 

flcJunkin, F.E. 1970. Engineering measu res for control of 
Schistos omi asis. Office of Health* Bureau of 
Technical Assistance* Agency for International 
Development. Washington, D.C* 20523. September 
1970. 

Messina, A. M. 1970. Planning of environmental and 
sanitary engineering activities in the Lake Nasser 
area, June-July 1970. EM/ES/163. Oct 1970* 

Mitwally, H. and El-Sharkaw, F. 1970. Methodology and 
application of measuring housing conditions for 
rural areas in O.A.R. and similar developing 
countries. Part I. Journal of the Egyptian Public 
M§2ciation 4 5(5): 420. 

Mobarkic, E* M. 1975* Faygum Control Project for 
Bilharziasis. Egyptian Ministry of Health. Cairo* 

169 















































Hoser^C.A. and Kalton^ G. 1972. Survey Methods in Social 
Investiga tio n. New York: Basic Books, 

Inc. Publishers. p. 467. 

Nagaty, H.F. and Bifaat, M.A. 1957. A parasitological 
survey of the Kharga and Dakhla Oases in 1952 and of 
the Kakhla Oases in 1955. Jour nal of the Ig.y£tian 
fl^^ical A sso ci ati on 40: 444. 

Nooman, 2.M.; Nafeh, M.A.; El-Kateb, H.; Atta, S.M.; and 
Ezzat, E.S. 1974. Hepatosplenic disease caused by 

ha eiaato biuiB in Opper Egypt. Journal of 
Med icine and H yg iene 22(2): 42-48. 

Cbeng, I.E. 1975. Health problems of the Volta Lake 
Ecosystem. In M an-mad e Lakes and Hu man Health, 
ed. Stanley, N.F. and Alpers, M.P. London: Academic 
Press, pp. 221-232. 

Omran, A.P.,; Kholy, A.M.; and El-Sayedali, 

A. 1962. Epidemiological basis of research in 
bilharziasis in Egypt. Pr oc ee di ng of International 
S ymposi nm on Bilharzi asi s, Part I. pp. 183-210. 

__.1966. Impact of economic development on health 

patterns in Egypt. Archives of Environm enta l H ealt h 
13: 117-124. 

_. 1973. Egypt: Population pro blem s and prospects. 

Chapel Hill, North Carolina: Carolina Population 

Center, University of North Carolina at Chapel Hill. 

Bifaat, H.A. 1964. A parasitological survey in Mersa- 
Matruah Government UAR. Journal of the Eg ypt ian 
Health Ass ociat ion 39 (1): 49. 

Bifaat, H.A. and Nagaty, H.F. 1970. A survey of parasitic 
infections including malaria and nutritional 
diseases in Nubia before the construction of the 
high Aswan Dam. Ain Shams jo urna l 22(2): 

155. 

Bifaat, M.A.; Salem, S.A.; and Horsy, T.A. 1963. 

Parasitological survey in El Naady El Gadeed, U.A.B. 
Journal of the Eg yptian Public Hea lth Ass ociation 
38: 199-202. 

Bifaat, W.A.; Salem, S.A.; and Nagaty, H.F. 1964. 

Parasitological and serological surveys in Wadi El 
Natrum UAR Jo urn al of the Egy ptian Public H ea1th 

Association _9 (1) : 17. 

Buffer, H.A. 1910. Note on the presence of B ilha r zia 

haematobia in Egyptian mummies of the Twentieth 

170 


































dynasty (1250-1000 B.C.)• British Medical Journal 1: 
16-25. 

Bussell, C,S* and Landsberg, H.H. 1971. Internal 
environmental problems—a taxonomy. Science 172 (25 
June): 1307-1314. 


Satti, M.H. 1969- 1970. Nasser Development Center 

J^ealth aspe cts) Npv^ 1970.^ 

Sherif, A.F. 1968. A new trend for controlling 

schistosomiasis in hyperendemic area at Iflaka 
O.A.R. by elimination of the parasite from man and 
vector. J our nal of the P ublic Health 

Association {j_ (1) : 3 0. 

Scott, D. and Chu, K.Y. 1974. Pro jec t IR 0658 

JSAf Research in t^ epidemiology and 

methodology of control of schistosomiasis in man- 
lakesj^ r epor t on a visit made from the 
based in Ghan a to Lake Kosson in Ivory Coast 

WPD/24.7 WHC unpublished. 

Scott, J.A. 1937. The incidence and distribution of the 
human schistosomiasis in Egypt. American Journal of 
Hyg iene 2J: 566-614. 

_.1969. Schistosomiasis control in water supply 

sources. Jou rna l of lb® A®l§£i£^i^ Water Works 
Associ ation 6J: 352-354. 

Shindy, Baligfa. 1977. Personal communication, Egyptian 
Ministry of Agriculture, Cairo. 

Sterling. C. 1972. Superdaras: the perils of progress. 

Boston: The Atlantic ll22fhll 

Company* April, pp. 35-41. 

Tuli, R.L. 1966. Report on a WHO mission for public health 
aspects of lake Nasser development. CPD/67,3. 

van der Schalie, H. 1960. Egypt*s new dam--asset or 
liability? The Biologist. 42: 63-70. 

1963. People and their snail borne diseases. 
Michigan Quarterly Review 2: 2,106-114. 

1972. World Health Organization Project Egypt-10: A 
* case history of a schistosomiasis control project. 
In The Carel ess T echnol ogyy od. M. T. Faruar and 
j.pT^iilton.' Garden City, New York: The Natural 

History Press. 


. 1974. Aswan Dam 


Revisited. 

171 


En viron men t 16(9): 

































18-20, 25-26. 


IJaddy, B.B. 1975. Sesearch into the health problems of 
raauraade lakes, with special reference to Africa. 
Transactions. Roy. Society. Tropical M ed icine and 
6S: 39-50. 

Warren, K.S. 1975. Schistosomiasis; se lecte d abstracts 
18 5^-19 "2. M.I.T. Press, Cambridge, Massachusetts 
and London, England. 

Warren, K.S. and Mahmoud, A.A. 1975. Algorithms in the 
diagnosis and management of exotic diseases 
I. Schistosomiasis. J ou rnal of Infectious Diseases 
13J (35); 61ii-620. 

Waterbury, J. 1971. M anpo wer and po pulati on plan n ing in 

A rab Repu bl ic of E3I£t_2^ ll Pop ulati on 

review 1971. American Universities Field Staff, 
Inc. XVIlT 27 

Waterbury, J. 1974. The balance of people^ land^ and 

is modern Egypt. American University Field 
Staff Inc.^XIX: 1. 

Webbw, G. 1972. Control of schistosomiasis in Ethiopia, 
Sudan, and east and west African countries. In 
Proceedings of a Sym posium on the Fu tu re of 
Schistosomiasis C ontr ol. ed. Miller, M. J. Tulane 
University, New Orleans, Louisiana, U.S.A. 

Webster, M.H. 1975. Medical aspects of the Kariba Hydro¬ 
electric scheme. In Man -made L akes an d Human Health. 
ed. Stanley, N.F. and Alpers, M.P. London: Academic 
Press, pp. 69-88. 

Weir, J.M. 1969. The unconguered plague. Rockefeller 
Foundat ion Cua rterly 2: 4-21. 

Weir, H.M. ; Wasif, I.M.; Hassan, F.R.; Attia, S.D.M.; and 
Kader, M.A. 1952. An evaluation of health and 
sanitation' in Egyptian villages. J ourna l of the 

Pu blic H ealth Association 29 (3) ; 55. 

White, W.H.; Dcbrovclny, C.G.; and Berry, E.G. 1958. Field 
trials of various molluscicides (chiefly Sodium 
pentachlorophenate) for the control of aquatic 
intermediate hosts of human bilharziasis. Bu ll etin 
2f lll§ World Health Organiz at ion J8: 9 63-97 47 ~ 

WHO. 1967. Measurement of the public healtl^ 2l 

bilharz ias is . Technical Reprint Serial Number 349. 

« A consideration of the economic impact 

172 


Wright, W.H, 1972 











































of schistoscifiiasis, of the Worl d Health 

SlSJ^ization 4.J: 559-566. 

Wright, M.H. 1973. Geographical distribution of 
schistosomiasis and their intermediate host. In 
^§119109Y and Con trol of Schi stosomias is 
iBilhar zias is). ed. Ansari, N. Baltimore: 
University Park Press. pp. 42-48. 

Zaghloul, A.Z. 1963. Rural health services in 
O.A.R. J ourn al oj the E gypti an Public Health 
Associa tion 38: 217-242. 

Zawahry, M.W. 1962. Biiharzia in Children 0-12. 

Pro ceed i ngs 1st Inte rnat iona l Sy mpos ium on 

Sliijiziasis Part I. pp. 211-228. 

_. 1964. A health survey in Egyptian Nubia. Journal of 

Bgyptiap Public He alth Association 39 (5) : 

313-340. 


173 

























APPENDIX I 


Resource Centers in Egypt 


This is a list of centers in Egypt where material on 
aspects of schistosomiasis and other tropical infections may 
be found. 

American University in Cairo, Library; Kasar El Aini Street, 
Cairo 

The Egyptian Ministry of Health, Library; Garden City, 
flagles El Shot Street, Cairo 

The High Institute of Public Health, Library; 165 El Horreya 
Street, Alexandria 

Naval American Research Unit-3; c/o S* Embassy, Garden 

City, Cairo 

American Cultural Library; Garden City, Cairo 
Cairo University Medical Library; Giza, Cairo 
British Cultural library; Dokki, Cairo 

World Health Organization, Library; Regional Office, 
Alexandria 


174 


APPENDIX II 


DATA FORMS 

CLINICAL EXAMINATION FORM 01 

Code: Village ID Family Id •••... Date 

Name and ID code •••• 


Relation to bead of household 
Sex 

Date of Birth 
Age 

Number of Years in Village 
Marital Status 
Number of Pregnancies 
Number of Live Births 
Number of Still Births 

Most Recent Medications/Date: 

First Diagnosis 
Second Diagnosis 

Urine Specimen 
S. haematobium 
S. mansoni 

Height (ci) 

Height (kg) 

comments 

Education 

Preschool Age 

School Age Not Attending 

Does Net Head or Write 

Beads Cnly 

Reads and Writes 

Has Completed Primary School 

Has Completed Secondary School 

Has Received Higher Education 

No Information 


175 





Occupation 

None 

Landowner (Non-Farmer) 
Farmer 

Farm Laborer 

Fisherman 

Boatman 

Domestic Servant 
Skilled Laborer 
Other Manual Laborer 
Clerical 
Professional 
Housewife 
Tourist Guide 
Other 


HOUSING FORM 02 


Date 
Village 
Name of Owner 
Address 

Year House was Built 


1* Construction material 


stone or red brick 1 
mud brick 2 

wood or reed 3 

2. Structure attachment 
detached 1 

one side only 2 

two sides 3 

three sides 4 

3* Painted walls 

exterior 1 

interior 2 

4. Yards 

present 1 

not present 2 

5. Staircase 

fixed 1 

mobile 2 

none 3 

€• Roof material 

concrete 1 

wood 2 


176 


reed 3 

mud 4 

7. Roof ccnditiofl 

permeable 1 

not permeable 2 

8* Storage place for 
fuel materials 
roof 1 

stable 2 

storage room 3 

yard 4 

none present 5 

9* Floor construction 

earth 1 

concrete 2 

tile 3 

vood 4 


10* Number of windows .... 


11. Lighting 

electricity 1 

kerosene 2 

other 3 

12. Television 

present 1 

absent 2 

13. Number of rooms 


14. Number of persons 

living in house ««•« 


15. Stable 
inside 
outside 
none 

16. Waste container 



yes 

no 



17. 

Animal 

waste 

materia 


stable 

1 

canal 


yard 

2 

roof 


street 

3 

none 

18. 

Cooking 

gas 

oil 

f uel 



1 

3 


177 



wood 3 

dung 4 

19. Stable cleaning 

daily 1 

weekly 2 

monthly 3 

never 4 


Form continued on next page 

20. Housing approach 


non-earth: 

clean 1 

littered 2 

dry 3 

wet 4 

earth: 

clean 5 

littered 6 

dry 7 

wet 8 

21. Screens 

yes 1 

no 2 

22. Mosquito nets 

yes 1 

no 2 

23. Ownership 

own 1 

rent 2 

24. Halls decorated 

inside 1 

outside 2 

none 3 

25. Water source 

public 1 

private 2 

surface 3 

ground, well 4 


26. Hater supply drinking bathing laundry utensils animals 

piped 
inside 
piped 
outside 
hand pump 
inside 


178 


hand pump 
outside 
canal 
drain 
lake or 
pond 

River Nile 

27. Storage of water 


ffletal ^ 

ceramic 2 

earthenware 3 

other 4 

28. Nastewater drainage 

concrete 1 

pipe 2 

trick 3 

tile 4 

earth 5 

other 6 

29. Latrine 

yes 1 

no 2 

30. Is the latrine used? 

yes 1 

no 2 

31. Is there a cover 

for the latrine? 
yes 1 

no 2 

Date of latrine 

installation....... 


32. Type of latrine 

borehole 1 
pit 2 
masonry walls 3 


hO. Water carriage present 
in the latrine? 
yes 1 

no 2 


34. Septic tank 
present ? 

yes 1 

no 2 


35. Cesspool present? 
yes 


1 


179 



no 2 

36. Location of 
latrine 

inside 1 

outside 2 

stable 3 


180 


HELL FORM 03 


Location Information: 

\illaqe ID Number 
Late 

Sell ID Number 


Type of well 


Depth of water level 
tiameter 

Number of months a year dry 
Date of installation 
State of repair 

Nearest latrine or wastewater disposal in meters 

Approximate number of users per day 

Drainage 

concrete 

brick 

tile 

earth 

Use 

drinking water 
drinking and washing 
washing only 
not used 

contamination of well water with drainage possible? 


181 


CANAL FORM 04 


Location Infornation: 

Village ID Number 
late 

Canal ID Number 


Date of construction 

length 

Width 

Depth 

Approximate discharge m^/day 

Irrigation canal: number of feddans irrigated 


Dse: 

drinking water supply (public use) 

drinking water 

bathing 

laundry 

washing utensils 
washing animals 
swimming 

wastewater disposal 
sewage outfall present 
animal waste disposal 

Septic 

Canal lined with concrete or tile 


182 


MOSQUE FORM 06 


Location Information; 

tillage ID Number 
Cate 

Mosque ID Number 
Mosque Name 


Date of construction 

Construction material 

stone or red brick 
mud brick 
wood or reed 

Interior yard and floor construction 

stone or tile 

reed 

earth 

concrete 

wood 

Ilectricity 

Sater supply 

public (piped) 

private: surface ground 

Drainage of wastewater 

concrete 

piped 

brick or tile 

earth 

other 

Drinking water 

piped 

stored 

metal container 
ceramic container 
other 


183 



Latrine 


present 

cover 

date of installation 
type 


184 


VILLAGE FOEW 07 


Location Information: 


Village ID Number 
Village Name 
Governorate 
Area 

Latitude 

Longitude 

1. Population 1976 

2. Total number of houses 1976 

3. Street sanitation 

Always free of solid waste and litter 
Has regular collection of solid waste 
Paved {% coverage) 

Large collections of solid waste present 
Wastewater and/cr mud present 

4. Public lighting 

Electric 

Oil 

None 

5. Solid waste collection service available for home 

6 . Public treated water supply yes no 

ground water surface water 
demand 

number of water points--outside in home 

number of taps working 
chlorination yes no 

7. Ground water levels 

8 . Public wells Private wells 

9. Climate 


185 


10. Terraiii--elevation from sea levels 

11. Agricultural practices and general 


etc. 

economy 


186 


WATER POINT FORM 09 


Location Inforraation: 

Village ID Nuisfcer 
Date 

Water Point ID Number 

Number of taps 

Number of taps working 

Date of installation 

Source of water 

well 

treated 

other 

Drainage area 

concrete 

brick 

earth 

Number of hours/day with flow 
Approximate number of users per day 
Ose 

drinking 

drinking and washing 
washing only 
cooking 
not used 


187 


LAKE AND POND FORM 10 


Location Information: 

tillage ID Number 
Date 

lake or Pond ID Number 


Size 


lengtb 

width 

depth 

Seasonal water levels 

winter 

spring 

summer 

fall 


drinking water 
bathing water 
laundry 

washing utensils 
washing animals 
swimming 

wastewater disposal 
sewage or latrines 
solid waste disposal 
animal waste disposal 

Number of drain outfalls present 

Septic 


188 


WATER TREATMENT PLANT FORM 11 


Location InforiaatioD: 


Village 

Cate 

Village ID Nurafcer 


1, Location of plant 

2. Date when plant first began to operate 
How long has the plant been operating? 

3* Population serviced: 

a. Does the plant serve the entire village? 

b* Does the plant serve less than the entire village? 

If sc, how nuch is covered? 
c. Does the plant serve other villages or places 
besides the village? industrial sites? 

4. Give location of the source of water used by the plant 
for treatment 

5. Obtain the volume of water treated by the plant: 
daily 

yearly 

6 * Describe each point where chlorination of water is 
carried out currently in the treatment process. 


How much chlorine is being used? 


7. Are there laboratory facilities to check the quality o 
the treated water? untreated? describe... 

8 - On the average how many hours each day does the 
distribution system have pressure? 

9. Is there a water storage tower present? capacity? 


189 


APPENDIX III 


CODE KEY AND CODING FOBMS 


CLINICAL CODE KEY 


1* Clinical data code fora number = 01 


2. Code nuaber of unit 01 to 20 


01 

Kazan Sharq 

02 

Guzaira 


03 

Abu Rish 

bahr i 

04 

Ga •afra 


05 

Ballana 


06 

Tushka 


07 

El Malki 


08 

Kurta 


09 

Kalabsba 


10 

Bimban 


11 

Barout 


12 

Sherif Pasha 

13 

Naii m 


14 

Beni Adi 


15 

Ashmant 


16 

El Agaze 

in 

17 

El Hamra 


18 

Mahalet 

El Kasab 

19 

Mahalet 

Mousa 

20 

Sheno 


Fami 

ly code 

number fr 

Code 

! number 

of person 

Cues 

;tion 1: 

Relation 

1 . 

Head of 

Family 

2 . 

Wife 


3. 

Male offspring 

4. 

Female o 

ffspring 


ffi 0001 

within the family from 01 
to the head of the family 


6 , Question 2: Sex of the person or individual 

1. Male 

2. Female 

7. Question 3; Date of birth. Use only the last two 
digits of the year of birth. 

1943--43 


190 


99 


= DO inforIliaticn 


Question 
Code for 
00 - 




01 

05 

10 

15 

20 

25 

30 

35 

40 

45 

50 

55 

60 

65 


01 
02 
03 
04 
05 
06 
07 
08 
09 
10 
11 
12 

13 

14 

15 


4 

age 


Age of the person 
groups 


or individual 


Example: 

recorded on data form as age group 25-30 
group code number = 07 


9. Question 5: 
in this village. 


Number of years that individual has lived 
Recorded directly as number of years. 


10. Question 6 : 


Marital status of individual 


1 Single 

2 Married 

3 Divorced 

4 Widoved 

11. Question 7: Number of pregnancies 99 means no 

information 

0 means none 


12. Question 8 : 
information 


Number of live births 


99 means no 


0 means none 


13. Question 9: Number of still births 99 means no 

information 

0 means none 

14. Question 10: Drugs taken for treatment of parasitic 

infection. 

Blank on data form means no information = 99 

Drugs or medication given fcr other infections means 

other =37 

iio medication or drugs received means none - 0 

#Thic maV be recorded on the data form as a slash) 

' ^ 191 


First two boxes are for month of year when drug was 
given 

Third box is for the year 1975 = 5 

15. Question 11: Diagnosis of individual 
A special code list is to be prepared 

16. Question 12: Same as question 11. 

17. Question 13: Examination for haema tobiu m infection 

Positive = 1 
Negative = 2 
No specimen 

18. Question 1^1: Examination for S_. mansoni infection 

Positive = 1 
Negative = 2 
No specimen = 3 

19. Question 15: Deleted 

20. Question 16: Deleted 

21. Question 17: Height of individual. Record directly as 
height. 

Last column for fraction 

22. Question 18: Neight of individual 


56 kilcgrams; record as 0560 
56.5 kilcgrams; record as 0565 


192 




23 


Question 19: 


The individual has not attended the examination =no 
response = 1 

The individual is no longer living in the village = 2 

The individual has died = 3 

Form is blank for question 19 = 99 

Stool specimen given = 4 

24. Education of the individual 

Record the number given 
If question is blank = 99 

25. Question 21: Swimming and bathing habits of the 
individual 

Record directly the number or numbers given 
Example: 4 is recorded as 0004 

1 and 4 is recorded as 0014, etc. 

Use ccfflbinations. 

26. Question 22: Occupation of the individual 

Record directly the number given in the same fashion as 
in question 20. If the question is blank = 99 Note: 
Additional occupations not listed on the data form may 
be written in the space for the code number. In this 
case the occupation should be listed in the code guide 
and given a code number and recorded in the same 
fashion as above. 


193 


APPENDIX IV 


Guide for Field Sur vey 
Standard Methods for Survey 


Protocol for Selection of Sample Population 


1. A family is a man and his, wife (s) and all unmarried 
children. Single adults (if selected) 
constitute a family. If a single adult 
parent (s) is selected, the parent (s) 

(only if living in the same village), 
unmarried children. 


who have no parents 
living away from his 
must also be located 
as well as all other 


2. It is net desirable to examine persons not selected from 
the sample frame. HOWEVER: older persons, village leaders 
and well known respected persons that desire to be included 
should be INVITED to the exam. Do not give a family code 
number to these families or persons. 

3. If a selected family member is missing but will return 
to the village before the end of the survey, complete the 
exam for all other family members, but hold clinical form 
until the missing family member returns and then complete 
the form by examining the remaining member. 

4. As families are selected from the sample frame they are 
simultaneously assigned a serial number starting with 0 0 1. 

5. This serial number automatically becomes the faraily*s ID 
code number and the ID code number for the family’s house. 

6 . After each family is examined, their name is checked off 
the sample frame. 


194 



Clinical Exam Routine Outline 


1* Before a selected family comes to the health unit (or 
center) a visit must be made to the home of the family by 
the health team engineer-sanitarian in order to: 


a) Inform the family about the clinical exam and that 
all members of the family should attend regardless 
of age or disability* (For those too disabled to 
leave the home the team from the unit must visit 
the home^ carry out the clinical exam^ and collect 
urine and stool samples) 

b) To inform the family that urine and stool 
specimens will be necessary at the health center. 

c) Tc complete the housing data form* 

2. The first step once the family arrives at the health 
unit or center is for the doctor to enter the family ID code 
number on the clinical exam form 01 and the individual code 
numbers* The individual code number is at the left hand 
margin where the individual's name has been entered on the 
data form* Each individual then will have a 7 digit code 
number comprised of the two code numbers for the village, 
three for the family, and the last two for the individual. 

CAUTION: Always take great care to avoid confusing 

individual ID numbers. 


3. The nurse, assistant, or physician completes the data 
form which is ncn-medical, i.e. occupation, education, age, 
etc* 

4* Urine specimens must be taken from each family member* 
The laboratory technician makes sure the specimen is given 
and placed in the correctly labelled container. The results 
of the examination of the urine are entered onto the data 

form. 


5* Stool specimens must be taken 
(cnly a small volume is nece 
technician copies the individual 
person giving the specimen on to 
vial. The stool specimen is tra 
the correctly labelled specimen via 


from each family member 
ssary) . The laboratory 
ID code number from the 
a plastic stool specimen 
nsferred with out d^ay to 
1 according to protocol. 


195 



6 , The weight and height of each family member is taken 
according to the protocol given and recorded in the 
appropriate place on the clinical exam data form 01* 

7. \ physical exam of each family member is made by the 
physician. A first and second diagnosis is made and this 
information is entered into the appropriate spaces on the 
data form. 


8 . The medication 
a very important 
physician cross-exa 
what, if any, medic 
for parasitic disea 


that may have been rece 
aspect. This will 
mine the person until 
ations have been taken, 
ses are of interest. 


ived previously is 
require that the 
it is determined 
Only medications 


196 


9 


Please note that blood films will not be taken. 


10. Check cff the family name from the sample frame. This 
will prevent seeing the same family twice and will help show 
how many families have been examined. 


11. Following the completion of the above activities the 
examination of the family ends. Go to the next family on 
the sample frame. 


197 




TECHNIQUE FOR PLACING 
THE PERSON IN THE CORRECT AGE GROUP 

DC NOT ATTEMPT TO ESTIMATE EXACT AGE 


00-01 
01-05 
05-10 
10-15 
15-20 
20-25 
25-30 
30-35 
35-40 
40-45 
45-50 
50-55 
55-60 
60-65 
65 + 

Note: This guide is to be used when the person to be 

examined has no record of birth date or government-issued 
identification card. 


198 


METHOD FCR COMPLETING THE DATA FORMS 


CLINICAL EXAM FORM 01 


Enter village 
village name. 


ID 


code nuraber in 


box given 


and fill in 


Enter the fafflily ID code number in the box given. This 

number has be the same as the house ID code number where the 
family lives, 

NOTE: One form is to be completed for each family, 

even if the family is only a single person, A family 
is a man and his wife (s) and all unmarried children. 
Single adults (if selected) who have no parents 
constitute a family. If a single adult living away 
from his parent is selected, the parents must also be 
located (only if living in the same village), as well 
as all other unmarried children. The entire family 
is then examined and all results are entered on the 
same clinical exam form 01, 


Enter data in box given: day month year. 

The name of each family individual is entered on the 
clinical exam form 01, Each member of the family then 
receives a tag with the village ID, family ID, and 
individual ID code number written (in this order) on the 
tag. The individual’s ID code number is taken from the left 
hand margin of the clinical exam form where the individual’s 
name has been entered. 


There is no given order in which to complete the form. 
This is left to the team to manage and to suit the 
organization at the health unit or health center. 

The following is a guide to each entry: 

1) Relation to head: Write in the appropriate space 
the relation to the head of the family for each 
member. 


2 ) 

3) 


Sex: enter male or female in the given space 


Enter date of birth by 
confirmed by checking 
card. 


year only. This is to be 
the government-issued ID 


4) 


Enter the age given by the individual. Do not 


199 


cooput€ 


age • 


5) Enter in the correct space the approximate number 
of years the individual has been living in the 
village. Confirm by checking on the location where 
the individual was born. 

6) Marital status: enter in the correct space single, 
married, divorce, or widowed. 

7) Enter in the correct space the number of 
pregnancies. If male or unmarried enter 0. 

8) same as above. 

9) same as above. 


10) Medication received: This cannot be left blank. 

Each person must be thoroughly checked. If there 
has not been any• medication received enter NONE in 
the correct space. If medication was received for 
illness other than parasitic infections enter 
CTHEF. If medications have been received for any 
parasitic disease, especially for bilharzia, enter 
name of drug received, and give month and year. 

11) Enter the first and second diagnosis in the correct 
spaces. 

12) Same as above. 



Orine: If the 

are negative for 
given space. If 
for l^iisoni. 
identified as ei 


results from the 
§ . haematobium 
positive, enter 
NOTE: all ova 

ther S. haeraatobi 


ine examination 
ter a 0 in the 
1. Do the same 
t be positively 
or S. mansoni. 


ur 

en 

a 

mus 

urn 


14) Same as above. 


15) Blood films: 
made • 


Originally, 


blood films were to be 


16) Same as above. 

17) Height and Weight: enter each measurement in the 

given space. Refer to standard methods guide for 
the measurement of height and weight to make sure 
that the data is obtained according to the desired 
technigue. 

18) Same as above, 

19) Comments: This has been 
in charge. 


200 


provided for the physician 




20) Education: Enter a 1 for each positive answer, 

Make sure that score is placed in the correct row 
and column. 

21) Swimming: ASK ”Hhere do you swim or bathe?**. 

After entering the answer in the correct given 
space ASK ”Where else do you swim or bathe?**. 

Continue asking this question until the person 
states that there are no other places where he or 
she swims or bathes. 

22) Occupation: After inquiry, enter 1 under the 

correct occupation in the space given. Make sure 
that the score is placed in the correct row and 
column. 

23) Stool specimen: Enter a 1 if stool specimen has 

been given. Always double check to see if the 

individual has given the specimen. 


201 



Urine Examination Protocol 


1. The entire voided urine is collected in a conical flask. 
The flask is numbered with the individual’s ID code number. 

2. The urine is allowed to settle without disturbance for 
30rainutes. 

^ clean pipette is used to collect the sediment and a 
drop of the sediment is placed on a clean glass slide. Two 
more drops are placed into an empty but coded specimen 
bottle. 

4. The slide is examined under the microscope for 
schistosome eggs. 

5. A specimen is not negative until all the sediment has 
been examined. 


6. ALL OVAL 

s. haematobium 


MUST BE POSITIVELY 
OR S. MANSGNI. 


IDENTIFIED AS 


EITHER 


202 




PROTOCOL FOR HANDLING STOOL SPECIMENS 


!• The stool speciaen is received* The ID nurober 
individual giving the specimen is immediately copied 
bottle with a felt-tip pen* 


of the 
onto a 


2. Stool is placed into the plastic stool specimen bottle 
in the following manner without delay. 


a) 

Open the 
a few dr 

bottle and 
ops of MIF. 

remove 

the 

inner 

plastic cap 

* Add 

fc) 

Hith a s 

mall wooden 

palm 

stick 

place 

very small 

nieces 

A. 


of stool in the bottle 
should be selected from a 
specimen. 


on the bottom. Each piece 
different area of the stool 


c) About one c.c. of stool should be transferred to the 
bottle. This may require 8 to 10 pieces and should be 
about the same amount as a ”foul” bean* 


d) Add a few more drops of MIF solution and mix the 
specimen until ail the stool has been completely broken 
up. 


NOTE: Two drops or .1 ml of urine sediment from the urine 

specimen should also be added to the correct corresponding 
stool specimen bottle. 

€) Add MIF solution until the bottle is almost full. 

Leave the neck of the bottle empty. 

f) Place the white plastic inner cap inside the black 

outer cap and then place both over the top. 

g) Carefully rock the inner cap into place with the black 

cap. Then remove the black cap and make sure the inner 
cap is firmly in place. Pressure can be applied with 
the black cap if the inner cap is still not in the 
desired position. 



Recheck and 
label. The 


make sure that the label is the correct 
bottle is now ready to be transported. 


203 


TECHNIQUE FOR THE MEASUHEHENT OF HEIGHT AND WEIGHT 


1) All selected family members are to be weighed and 
measured for height regardless of age or disability. 

2) Procedure for the determinaticn of weight. 


a) each member is weighed with a minimum amount of 
clothes and without shoes. (NOTE: regardless of 
how much clothes are worn during weighing make sure 
that all wear the same amount of clothes daring 
weighing. Do not allow one person to be weighed 
fully clothed and then weigh the next half clothed. 


b) Infants that cannot stand unsupported are to be 
weighed with the mother after the mother’s weight 
has been taken and recorded. (Infants should be 
clothed only in diapers) When an infant is 
weighed in this manner he total weight of the 
mother and child is recorded. 


c) Check each week that the scales are working 
correctly by weighing known standards. 


3) Procedure for the determination of height. 


Adults 

a) 


b) 


c) 


Place the tape in a convenient place on the wall. 
The person’s heels, buttocks, shoulders, and back 
of head should touch the wall. The tape should be 
directly behind the head. 

Remove all head gear if it has not already been 
removed. This includes turbans, hats, scarves, 
etc. 

Place a right angle (book, etc) against the wall 
and press down to the top of the head. Contact 
has to be made with the top of the head. 


d) Record height to the nearest 0.5 cm. 


Infants 


204 



AIL infants who cannot walk are to be measured 
lying down. 

This will require two persons to take the 
Beasurement. 

One person holds the head firmly against a 90° 
upright. 

The other person straightens the body by holding 
the ankles together with one hand, while with the 
other hand the 90° sliding upright is placed 
firmly against the infant’s feet. 


205 


TECHNICAL REPORT DATA 

(Please read Instructions on the reverse before completing) 

1. REPORT NO. 2. 

EPA-600/1-78-070 

3. RECIPIENT'S ACCESSI Ol^ NO. 

4. TITLE AND SUBTITLE 

SCHISTOSOMIASIS IN RURAL EGYPT; A Report of U.S.- 

Egyptian River Nile and Lake Nasser Research Project 

5. REPORT DATE 

December 1978 

6. PERFORMING ORGANIZATION CODE 

7. AUTHOR(S) 

F.D. Miller, M. Hussein, K. Mancy, and M.S. Hilbert 

8. PERFORMING ORGANIZATION REPORT NO. 

9. PERFORMING ORGANIZATION NAME AND ADDRESS 

University of Michigan 

Ann Arbor, MI 48109 

University of Alexandria 

Alexandria, A.R. Egypt 

10. PROGRAM ELEMENT NO. 

1BA609 

11. CONTRACT/GRANT NO. 

Special Foreign Currency 
Project No. 03-542-1 

12. SPONSORING AGENCY NAME AND ADDRESS 

Environmental Research Laboratory—Athens, GA 

Office of Research and Development 

U.S. Environmental Protection Agency 

Athens, GA 30605 

13. TYPE OF REPORT AND PERIOD COVERED 

Final 

14. SPONSORING AGENCY CODE 

EPA/600/01 

15. SUPPLEMENTARY NOTES 

16. ABSTRACT 

The objectives of this study were to provide current information on the prevalence 
of schistosomiasis throughout Egypt, to establish trends in the prevalence of schisto¬ 
somiasis in order to shed light on the potential changes caused by the Aswan High Dam, 
and to determine correlations between certain environmental variables and the preva¬ 
lence of the disease. Prevalence was invariably higher in male adolescents with the 
differential between sexes increasing from north to south. The prevalence was signifi¬ 
cantly lower in those villagers who obtained water for domestic use from protected 
supplies. The effect of population growth and migration from rural to urban areas is 
discussed. Results based on trend analysis of current and past data indicated a strong 
decline in overall prevalence of the disease in rural populations over the past 40 year 
The data did not show an increase in the overall prevalence of schistosomiasis follow¬ 
ing the construction of the Aswan High Dam.. The Nubian population also experienced a 
decrease in prevalence following relocation, with some villages benefiting more than 
others. Environmental conditions were also correlated against schistosomiasis preva¬ 
lence and additional aspects of transmission is discussed. 

► 

17. KEY WORDS AND DOCUMENT ANALYSIS 

a. DESCRIPTORS 

b. IDENTIFIERS/OPEN ENDED TERMS 

c. COSATI Field/Group 

Disease Vectors 

Infectious Diseases 

Schistosomiasis 

Public Health 


06F 

13B 

, 

' 

‘ 

1 

1 

i 

; ! 

13. DISTRIBUTION STATEMENT 

RELEASE TO PUBLIC 

19. SECURITY CLASS (This Report) 

UNCLASSIFIED 

21. NO. OF PAGES 

224 

20. SECURITY CLASS (This page) 

UNCLASSIFIED 

22. PRICE \ 


EPA Form 2220-1 (9-73) 


206 


☆ u. S. GOVERNMENT PRINTING OFFICE: 1978 — 657-060/1544 

















































EPA-600/1-78-070 





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